医生工作生态视角下的分级诊疗机制建模与实证研究

Failure to achieve orderly diagnosis and treatment is one of the important factors that influence doctors' satisfaction and social stability in our country and is one of the important reasons leading to difficulties of patients in getting medical treatment. Also, working ecology of all kinds of doctors at all levels hasn't been defined scientifically including the nature and content of their work and their working environment. Furthermore, we lack practical hierarchical diagnosis and treatment standards, procedures, management and oversight mechanisms. Hierarchical diagnosis and treatment is a complex system involving macro-social environment, micro-psychology and work factors. System dynamics and ecosystems are important methods and tools to conduct complexity science research, and they can be used to conduct comprehensive research on a large, complex multi-level multi-sectoral system. Based on systematical analysis theory and working ecology of doctors, this research puts an integrity of doctors and their working ecological environment into hierarchical diagnosis and treatment system and theoretically defines and discusses the working mechanism of doctors' working ecology from both the macro and micro level. By researching on factors that influence hierarchical diagnosis and treatment, constructing and verifying doctors’ working ecology mechanism and mathematical model to define hierarchical diagnosis and treatment by empirical evidences, this research tries to explore the optimal working ecological zone of doctors. Thus, it provides coping strategies to the hierarchical diagnosis and treatment mechanism in China. Moreover, it provides theoretical and technical support to improve timeliness and continuity of medical services, to promote the construction of grassroots medical institutions and health service system, and to create a reasonable and orderly medical environment.

影响我国临床医生满意度和稳定性，导致患者“看病难”的重要原因之一是未能实现有序诊疗，缺乏对各级各类医生工作生态（工作性质、工作内容和工作环境）的科学界定，进而缺乏可操作性的分级诊疗标准、程序、管理和监督机制。分级诊疗是一个涉及宏观社会环境，微观心理、工作因素的复杂系统，以往的研究多局限于政府层面、制度层面，以及卫生服务供给层面，而从系统和生态角度，从医生工作层面考虑的较少。本研究基于生态系统理论和医生工作生态视角，应用系统动力学分析方法，将医生及其工作生态环境作为整体并置于分级诊疗系统，进行医生工作生态的理论界定和作用机制的探讨,构建医生工作生态机制和分级诊疗机制的数学模型并进行实证验证，寻找医生最佳工作“生态区”，为我国建立分级诊疗机制，提高医疗服务的及时性和连续性,促进和完善医疗机构卫生服务体系建设以及创建合理有序的医疗环境提供理论和技术支持。

影响我国临床医生满意度和稳定性，导致患者“看病难”的重要原因之一是未能实现有序诊疗，缺乏对各级各类医生工作生态的科学界定，进而缺乏可操作性的分级诊疗标准、程序、管理和监督机制。本研究基于生态系统理论和医生工作生态视角，首先完成了医生工作生态的理论界定和作用机制的探讨，并通过系统综述和实证研究，完成对医生工作生态界定的调整。认为在分级诊疗过程中，影响医务人员双向转诊的制约因素有工作报酬、能力提升、职务晋升、工作环境、人际关系、岗位责任感，影响患者双向转诊的制约因素有就诊质量、经济负担、医疗环境、人际关系、转诊认知，调控医务人员和患者的制约机制是工作绩效、伦理道德、制度规范和筹资机制。同时，通过实证研究进行了医生满意度分析，发现医院医生和社区医生的满意度分别为3.35±0.82和2.81±0.84,两者间差别有统计学意义。影响医生满意度的因素有性别、文化程度、职称和医生类别；总体满意度与工作本身、工作环境、人际关系、领导管理、薪酬福利有相关性。进一步应用系统动力学分析方法，逐步纳入不同因素到模型中，构建了从社区卫生服务初诊到双向转诊，从微观到宏观，从简单到复杂的分级诊疗界定的数学模型。并通过分析整体与局部的关系，在构建局部因果关联回路的基础上，形成整体的因果关系图，即医生工作生态系统动力学模型，明确正反馈因素和负反馈因素，进而提出可明确区分的最佳医生工作“生态区”。经检查和运行显示模型量纲匹配一致、运行无错误，无极端结果；采用门急诊总人次数、医院门急诊总人次数和基层门急诊总人次数的历史数据与模型仿真结果比较，误差率基本在5%以下。综合分析显示从患者、社区医生和医院医生的角度看，患者的就诊选择是影响社区首诊的最重要因素。改变患者的就诊选择，重心是社区医生而不是医院医生，需要改变社区医生的生态环境，提高社区医生的诊疗水平，同时减轻患者就诊的疾病负担，以及提高患者对分级诊疗制度的认知水平。