N***S
发帖数: 189 | 1 医疗改革离不开高等医学教育，住院医生培训体制和学位制度的改革。医生社会地位和
收入的提高同样离不开高等医学教育，住院医生培训体制和学位制度的改革。没有高等
医学教育，住院医生培训体制和学位制度的改革，医疗改革就解决不了合格的医疗人才
从哪里来的问题。没有合格的医疗人才就不可能有医生社会地位和收入的提高。中国整
体医疗水平低下是一个世界范围内没有争议的问题。而这一问题又和高等医学教育，住
院医生培训体制和学位制度息息相关。这也导致了对外国医生准入门栏极低（甚至没有
语言关），和美国形成了鲜明对比。
本人借丁香园的平台， 对比中美两国体制，希望能够激起广大医学同仁的积极讨论。
并希望最后由文笔好的同仁总结成一篇论文样的文章，呈交给人大等部门。希望能广泛
讨论，传播。也希望最终能促进医疗改革。（有点过于雄心勃勃了。）
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[sub][b]A： 美国体制：世界上最成熟的医学教育体制。世界的样板。[/b]
[/sub]
*****************************************************************
A1。 中国人的认知 Quote:
==========================================================================
教学机制"与"精英教育"--美国、加拿大现代医学学位与研究生教育体制的两个特征
北美地区大学对医学院与附属医院、教育医院的管理体制采取不同的模式,"教学机制
"是维系医学院与医院关系的根本.北美医学高等教育只设博士学位,医学博士学位(MD)
和行医执照的获得是分离的,北美的医生学习和培训所需时间可长达16年之久,并需要通
过多次考试.MD教育强调基础和临床结合.北美公共卫生学位教育不属医学范畴,主要是
大学毕业后教育.我国高等医学教育可以借鉴北美模式,设定科学合理的学制、管理体制
和学位制度,加强大学对附属/教学医院的管理,明确其教育功能,健全医师资格考试制度.
作 者：
李军 石鹏建 汪玲 卢晓斌 董哲 李春英 陆敏
作者单位：
李军,董哲,李春英,陆敏(国务院学位委员会办公室副主任,北京,100816)
石鹏建(教育部高等教育司农林医药教育处处长,北京,100816)
汪玲(复旦大学研究生院副院长,上海,200032)
卢晓斌(北京大学国际合作部副部长,北京,100083)
期 刊：
学位与研究生教育 PKUCSSCI
Journal：
ACADEMIC DEGREES & GRADUATE EDUCATION
年，卷(期)：
2003, ""(6)
分类号：
G4
===================================================================
A2。 美国人的认知：http://en.wikipedia.org/wiki/Medical_education_in_the_United_States
Medical education in the United States includes educational activities
involved in the education and training of medical doctors (D.O. or M.D.) in
the United States, from entry-level training through to continuing education
of qualified specialists.
[hide]
* 1 Medical school
* 2 Internship
* 3 Residency
* 4 Fellowship
* 5 Board certification
* 6 Footnotes
* 7 See also
[edit] Medical school
Main article: Medical school in the United States
In the United States a medical school is an institution with the purpose of
educating physicians in the field of medicine. Admission into medical school
may not technically require completion of a previous degree; however,
applicants are usually required to complete at least 3 years of "pre-med"
courses at the university level because in the US medical degrees are
classified as Second entry degrees. Once enrolled in a medical school, the
course of study is divided into two roughly equal components: pre-clinical (
consisting of didactic courses in the basic sciences) and clinical (
clerkships consisting of rotations through different wards of a teaching
hospital). The degree granted at the conclusion of the four years of study
is Doctor of Medicine (M.D.) or Doctor of Osteopathic Medicine (D.O.),
depending on the medical school; both degrees allow the holder to practice
medicine after completing an accredited residency program.
Further information: Comparison of MD and DO in the United States
[edit] Internship
Main article: Internship (medicine)
During the last year of undergraduate medical education, students apply for
postgraduate residencies in their chosen field of specialization. These vary
in competitiveness depending upon the desirability of the specialty,
prestige of the program, and the number of applicants relative to the number
of available positions. All but a few positions are granted via a national
computer match which pairs an applicant's preference with the programs'
preference for applicants.
Historically, post-graduate medical education began with a free-standing,
one-year internship. Completion of this year continues to be the minimum
training requirement for obtaining a general license to practice medicine in
most states. However, because of the gradual lengthening of post-graduate
medical education, and the decline of its use as the terminal stage in
training, most new physicians complete the internship requirement as their
first year of residency.
Notwithstanding the trend toward internships integrated into categorical
residencies, the one-year "traditional rotating internship" (sometimes
called a "transitional year") continues to exist. Some residency training
programs, such as in neurology and ophthalmology, do not include an
internship year and begin after completion of an internship or transitional
year. Some use it to re-apply to programs into which they were not accepted,
while others use it as a year to decide upon a specialty. In addition,
osteopathic physicians "are required to have completed an AOA-approved first
year of training in order to be licensed in Florida, Michigan, Oklahoma and
Pennsylvania." [1]
[edit] Residency
Main article: Residency (medicine)
Each of the specialties in medicine has established its own curriculum,
which defines the length and content of residency training necessary to
practice in that specialty. Programs range from three years after medical
school for internal medicine to five years for surgery to seven to eight
years for neurosurgery. This does not include research years that may last
from one to four years if a PhD degree is pursued. Each specialty training
program either incorporates an internship year to satisfy the requirements
of state licensure, or stipulates that an internship year be completed
before starting the program at the second post-graduate year (PGY-2).
[edit] Fellowship
Main article: Fellowship (medicine)
Many highly specialized fields require formal training beyond residency.
Examples of these include cardiology, endocrinology, oncology after internal
medicine; cardiothoracic anesthesiology, cardiothoracic surgery, pediatric
surgery, surgical oncology after general surgery; reproductive endocrinology
/infertility, maternal-fetal medicine, gynecologic oncology after obstetrics
/gynecology. There are many others for each field of study. In some
specialties such as pathology and radiology, a majority of graduating
residents go on to further their training. The training programs for these
fields are known as fellowships and their participants are fellows, to
denote that they already have completed a residency and are board eligible
or board certified in their basic specialty. Fellowships range in length
from one to three years and are granted by application to the individual
program or sub-specialty organizing board. Fellowships often contain a
research component.
[edit] Board certification
Main article: Board certification (medicine)
The physician or surgeon who has completed his or her residency and possibly
fellowship training and is in the practice of their specialty is known as
an attending physician. Physicians then must pass written and oral exams in
their specialty in order to become board certified. Each of the 26 medical
specialties has different requirements for practitioners to undertake
continuing medical education activities.
＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝
＝＝＝＝＝＝＝
A3。 美国的医生助理体制：http://www.aapa.org/about-pas/our-history
In the mid-1960s, physicians and educators recognized there was a shortage
and uneven distribution of primary care physicians. To expand the delivery
of quality medical care, Dr. Eugene Stead of the Duke University Medical
Center in North Carolina put together the first class of PAs in 1965. He
selected Navy corpsmen who received considerable medical training during
their military service and during the war in Vietnam but who had no
comparable civilian employment. He based the curriculum of the PA program in
part on his knowledge of the fast-track training of doctors during World
War II.
On October 6, 1967, Duke University PA program graduated the first PA
students who went on to start practicing as PAs. Today there are over 79,000
graduates of PA programs.
Physician assistants are health care professionals licensed, or in the case
of those employed by the federal government they are credentialed, to
practice medicine with physician supervision. As part of their comprehensive
responsibilities, PAs conduct physical exams, diagnose and treat illnesses,
order and interpret tests, counsel on preventive health care, assist in
surgery, and write prescriptions. Within the physician-PA relationship,
physician assistants exercise autonomy in medical decision making and
provide a broad range of diagnostic and therapeutic services. A PA's
practice may also include education, research, and administrative services.
PAs are trained in intensive education programs accredited by the
Accreditation Review Commission on Education for the Physician Assistant (
ARC-PA).
Because of the close working relationship the PAs have with physicians, PAs
are educated in the medical model designed to complement physician training.
Upon graduation, physician assistants take a national certification
examination developed by the National Commission on Certification of PAs in
conjunction with the National Board of Medical Examiners. To maintain their
national certification, PAs must log 100 hours of continuing medical
education every two years and sit for a recertification every six years.
Graduation from an accredited physician assistant program and passage of the
national certifying exam are required for state licensure.
For more information about the history of the PA profession, visit the PA
History Center Web page.
＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝＝
＝＝＝＝＝＝＝＝＝＝
A4。 美国医学院和学生数目的控制：http://www.ikepu.com/book/nouse/ourside_economics_10_total.htm(未能找到英文资料，欢迎补充)
Quote:
============================================================================
=====
从根本上说，医学院受到来源于国家认证要求的限制，这一认证普遍禁止私营的医学院
(以营利为目的的医学院)。医学院必须得到国家的认证，以使其毕业生被准许参加行医
所必需的许可考试。如果我们回顾本世纪的最初10年，我们发现当时美国有192所医学
院，到了1944年，减少到69所。每10万人中的内科医师人数从1900年的157人下跌到
1957年的 132人。这些数字急剧下降的原因便是美国医学协会在控制医生数量方面的成
功。
对医学院的管制和认证是建立在所谓弗莱科斯纳报告的发现之上的。1910年，声誉
卓著的卡内基基金会雇佣亚伯拉罕·弗莱科斯纳检查美国当时已有的医疗教育机构，弗
莱科斯纳的建议方案导致当时已有医学院的一半寿终正寝。有趣的是弗莱科斯纳(他自
己非但不是医生，甚至连科学家都不是)考察的是医学院的投入而不是它的产出。他不
是去了解各个不同的医学院毕业生如何好或是如何称职，而是看他们是如何接受教育的
，这就等于说，你的老师根据你花费多少小时学习来给你打分，而不是根据你期末考试
临场的实际成绩评分。
对医学院限制的目的是由美国医学协会医学教育理事会前主席所描述的。他在1928
年曾这样说：“将医学院的数目从160所削减到80所(产生)的结果是学医的大学生和研
究生数目的下降。我们已经预计到这一点，并感到这是我们所希望得到的结果。我们已
经有了大量过剩的水平低下与平庸之执业者。”
===========================================================================
A5. 学术学位 and 临床学位。
Quote1:
http://www.wisegeek.com/what-is-a-professional-degree.htm
A professional degree 专业学位is generally a college degree that allows you
to work in a certain profession.
The professional degrees 专业学位 that require doctorate level training
include the following:
* MD or medical doctorate
* DO or Doctor of Osteopathy
* JD or Juris Doctor
* Doctor of Veterinary Medicine (DVM)
* Doctor of Dental Surgery (DDS)
* PhD in fields like psychology or pharmacology
Quote2:
http://en.wikipedia.org/wiki/Academic_degree#Canada_and_United_
Academic_degree学术学位
In the United States and Canada, most standard academic programs are based
on the four-year bachelor's degree (most often Bachelor of Arts, B.A., or
Bachelor of Science, B.S.), a one- or two-year master's degree (most often
Master of Arts, M.A., or Master of Science, M.S.; either of these programs
might be as much as three years in length) and a further one or two years of
coursework and research, culminating in "comprehensive" examinations in one
or more fields, plus perhaps some teaching experience, and then the writing
of a dissertation for the doctorate (most often doctor of philosophy, Ph.D.
or other types such as Ed.D., Psy.D., Th.D.) for a total of ten or more
years from starting the bachelor's degree (which is usually begun around age
18) to the awarding of the doctorate. This timetable is only approximate,
however, as students in accelerated programs can sometimes earn a bachelor's
degree in three years or, on the other hand, a particular dissertation
project might take four or more years to complete. In addition, a graduate
may wait an indeterminate time between degrees before candidacy in the next
level, or even an additional degree at a level already completed. Therefore,
there is no time-limit on the accumulation of academic degrees.
Some schools—mostly junior colleges and community colleges, but some four-
year schools as well—offer an associate's degree for two full years of
study, often in pre-professional areas. This may stand alone, or sometimes
be used as credit toward completion of the four-year bachelor's degree.
[b]Professional degree专业学位：
[i]In Canada and the United States, there is also another class of degrees
called "[b]First Professional degree[/b]"专业学位. These degree programs are
designed for professional practice in various fields other than academic
scholarship. Most professional degree programs require a prior bachelor's
degree for admission, and so represent at least about five total years of
study and as many as seven or eight. Some fields such as fine art,
architecture, or divinity call their first professional degree a "master's
degree" (e.g., M.F.A., M.B.A.) because most of these degrees require at
least the completion of a bachelor's degree. There is currently some debate
in the architectural community to rename the degree to a doctorate in the
manner that was done for the law degree decades ago, however, this would
also require increasing the length of their education.[citation needed]
In Canada, professional degrees in medicine (the M.D.) and law (the J.D.)
are considered to be undergraduate degrees [21][22][23][24] whereas MD, JD
or D.O. are doctorates in the United States.[25][/i][/b]
*********************************************************************
[b]
[sub]B. 中国的体制及反思：http://news.sohu.com/20080505/n256672879.shtml[/sub][/b]
**********************************************************************
..... .......
希望促进教育部和卫生部的合作
《望东方周刊》：两相比较，中国的医学教育有何不足？
胡应洲：主要有三方面的问题。首先，医学教育应该标准化、流水线化。中国培养
一名医学学生到底需要几年？中国的医学教育大部分是在高中毕业后开设5年的课程。
然而最近几年，许多医学院将学制改成了6年、7年甚至8年。而原本中国仅有一所8年制
医学院，也就是由美国洛克菲勒基金会于1917年创办、以约翰斯.霍普金斯大学为榜样
的中国协和医科大学。教育部的官员告诉我，目前中国每年会有720名8年制的医师从12
所医学院毕业。
其次，由于没有标准化的教育，医学院录取很多学生，但出来后却没有足够的医院
接收，毕业生很多没出路，不能成为医生，而是去做医药代表。这是更大的危险，一定
要对这个问题引起重视。
第三，医科学生毕业后临床经验参差不齐。其实医学后期教育可以分为两种学位，
一种是学术学位，另一种是临床学位。
《望东方周刊》：“标准化”的标准应如何制定？
胡应洲：就中国实行的合格标准我没有做过仔细彻底的研究，只是在此发表浅见。
然而我有在美国、英格兰学习和在香港的医学院教学的经历。以上三地在专业训练方面
都有既定明确的标准。
中国是否引进美国医学院的教育模式还有待商榷。我真诚地希望教育部深入监管医
学学位的授予情况，卫生部有效地利用医疗服务的资源以使中国医学院的课程体制更为
现代化，时间安排更合理。
中国医学教育最需要解决的问题是应当建立一个有统一标准的临床医学教学体系，
这样医学研究生才能获得合适的研究性训练。
实习医生应该通过严格的测试，以获得能够证明其能力的证书或学位，这样公众就
能够放心让实习医生医治，也可以使他们的医疗服务得到恰当报酬。就我所知，规范化
的医学毕业生能力测试项目还没有在全国实行开来。
关于医学教育，特别是研究生阶段存在的问题，陈竺部长非常关心。我希望促进教
育部和卫生部的合作。最近，我也和教育部负责医学教育的官员有过交流，他们告诉我
教育部已经意识到一些问题的存在。两个部的官员已经组织发起了共同探讨提高医学研
究生教育的会议。
很多钱应该花在疾病的预防和控制上
《望东方周刊》：你如何看待看病难看病贵的问题？
胡应洲：“看病难看病贵”是世界性问题，需要通过资源合理分配来解决这个问题
。中国不需要效仿美国的医疗制度。在美国，医疗保健占了约15%的国内生产总值。在
中国，我相信这个数字只有3%至4% 。这是一个很大的差别。
其次，中国需要进一步研究制定合理的医疗报账及激励制度，以形成一种良好的经
济模式，鼓励医院和医务人员懂得节约，以及如何运用最有效而非最贵、最新的治疗方
法。
第三，中国从农业经济到城市经济的过渡中，遭遇了很多问题。这两个阶段的发展
，需要有不同的做法。一劳永逸消除大众诟病的方法根本不存在。对于医疗来说，公平
的财务和分配是一项非常先进的科学，并且国家与国家之间各不相同。我建议，邀请国
内外专家以及相关公民和政府官员探讨这些问题。
《望东方周刊》：新医改方案即将亮相，你认为中国的医疗领域中最迫切需要解决
的问题是什么？
胡应洲：全国最重要的是农村，应该推动农村医疗，而农村医疗最缺少的是全科医
生。中国医生特别专科，最重要的是普通内科。
另外，医疗预防体系非常重要。美国的医疗投入有20%用在病人最后3个星期的生命
里，这不合经济和伦理，很多钱都应该花在疾病的预防和控制上。
预防包括三方面。一个是禁烟。美国已经推行禁烟运动40年，取得很大效果。减少
抽烟可以大大减少心脏病、肺癌、慢性支气管炎等疾病的患病几率。美国疾病预防中心
公布的一项资料显示，美国成人吸烟的比例从1993年的25%降到了2004年的20.9%。我也
曾向陈竺部长提议，要求在中国推行禁烟运动。第二是预防肥胖。另外，注射疫苗也是
重要的疾病预防措施。
《望东方周刊》：你对新医改方案有何意见和建议？
胡应洲：我跟陈竺部长谈过关于医改的问题。他和部门同仁都面临着巨大的挑战，
因此也承受着巨大压力。巧妇难为无米之炊，真困难。
《望东方周刊》：“巧妇难为无米之炊”，具体指的是什么？
胡应洲：相较于其他国家，中国卫生部能运用的资金占国内生产总值的比例，要大
大小于平均水平。英国全国医疗投入占了GDP的大约6%~7%。资金不足是卫生部面临的很
大问题，要用如此有限的资源来推动医改，几乎是不可能完成的任务。
陈竺部长和我谈过关于发展两个体系。一个是农村地区卫生监测站推广计划，以帮
助困难病例，应用现代技术。这是跳跃式的革新进程，就像手机在中国广泛使用并不需
要等到地面信息线路发展完备。另一个是发展城市医疗体系，政府应向公众提供最低限
度的灾难性保险，雇主和市民也需要购买不同领域的保险。
我相信他们最终会找到一个方法。当然，整个世界都在为医疗问题寻找答案，不仅
是中国。■ |
|
