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1、定义定义“以病人为中心的医学以病人为中心的医学”Defining “Patient-Centered Medicine” 来自:NEJM(2012-03-01) 有 29 次阅读 分享 (0) 返回本期列表 作者作者： Charles L. Bardes, M.D. PMIDPMID： 暂无 A patient consults an orthopedist because of knee pain. The surgeon determines that no operation is indicated and refers her to a rheumatologist, who fin
2、ds no systemic inflammatory disease and refers her to a physiatrist, who sends her to a physical therapist, who administers the actual treatment. Each clinician has executed his or her craft with impeccable authority and skill, but the patient has become a shuttlecock. Probably a hassled, frustrated
3、, and maybe bankrupt shuttlecock.The themes are very old. The Hippocratic Oath itself enjoins physicians to maintain their deportment and privileges while keeping the patients interests foremost. What is the proper relation between the doctors and the patients experiences of illness? Between a scien
4、tific understanding of disease, whatever the science of the day may be, and the subjective phenomenon of being sick? Between the subspecialist and the general physician? Between cure and care?“Patient-centered medicine” is the newest salvo in these ancient debates. As a form of practice, it seeks to
5、 focus medical attention on the individual patients needs and concerns, rather than the doctors. As a rhetorical slogan, it stakes a position in contrast to which everything else is both doctor-centered and suspect on ethical, economic, organizational, and metaphoric grounds.The British psychoanalys
6、t Enid Balint appears to have coined the term in 1969. She described a form of mini-psychotherapy that general practitioners could provide for persons who had illnesses that were partially or wholly psychosomatic.1 Her concept contrasted with “illness-oriented care” and meshed well with other critiq
7、ues of modern medicines emphasis on pathophysiology to the exclusion of other means of knowing and treating the patient. Landmarks in this paradigm shift have included Engels proposal for a biopsychosocial model that would “take into account the patient, the social context in which he lives, and the
8、 complementary system devised by society to deal with the disruptive effects of illness”2; Cassells transcriptions of clinical encounters, which provided an empirical basis for understanding the doctorpatient relationship3; and Kleinmans definitions of “disease” and “illness” as contrasting the doct
9、ors understanding of disordered biomechanics with the patients subjective experience of feeling sick.Contemporary forces have bolstered this movement. The growing demands for quality and safety in health care have refocused attention on patient outcomes, even if efforts to ensure more consistently p
10、ositive outcomes sometimes reduce the physicians prized autonomy. Grave concerns about the exorbitant price of medical care in the United States have led to considerations of whether shifting care from the subspecialist to the primary care physician could reduce its cost. The patient-centered medica
11、l home would reinstate the primary care office as the main locus of health care, provided that it can offer such desiderata as longitudinal personal care, access on demand (by visit, telephone, and e-mail), coordination among subspecialists, home-based and social services, open medical records, pay
12、for performance, and a functioning electronic infrastructure. Alas, these services, however admirable, are also expensive and would require that health care dollars be reapportioned from procedurally based subspecialists, whose incomes currently vastly exceed those of generalists.Supporting these re
13、cent trends is a new concept of the patient as consumer. The individual once the subject of a monarchy whose purpose was to obey, then the citizen of a state whose purpose was to participate in the polity and vote has now become the consumer in a marketplace whose purpose is to purchase. If the pati
14、ent is reconceived as a consumer, new priorities take center stage: customer satisfaction, comparison shopping, broad ranges of alternatives, choice, and unimpeded access to goods and services. Supplementary themes include the provision of information by advertising or other means, the stimulation (
15、and fulfillment) of demand and desire, marketing, branding, and estimations of value. Although some have argued that consumers would make wise, cost-conscious, and informed decisions in a free health care marketplace,5 the peculiar nature of medical insurance means that patients seldom pay directly
16、for the goods and services they consume and that their incentives for cost restraint are therefore absent. If doctors often make expensive choices, so do patients, and in my practice of general medicine I must often dissuade patients from demanding MRIs for their sore joints, antibiotics for their respiratory infections, and “brand name” medications for their hypertension, hyperlipidemia, and diabetes.Patient-centered medicine is, above all, a metaphor. “Patient-centered” cont
