患者与医院不断变化的关系
                                        ——形势与对策
                             廖新波

 

    这是我2002年在中欧国际工商管理学院读EMBA课程时的作业，今天在外地学习，中午没有午睡的习惯，翻阅了电脑论文文库，发现我还是在广东省人民医院从事医院管理工作时，我医院管理的思路与今天行政管理的思路没有多大改变。如果今天大家读起来觉得“有问题”，敬请原谅，因为我还是想保持其原汁原味。

   The constantly changeable relation between patient and hospital
——Situation and countermeasure
    Dr. Liao xinbo，Vice President, Guangdong provincial people's hospital

 

    医疗改革将对医院产生什么样的影响？中国加入世界贸易组织后医院该如何办？患者角色不断变化对医院有何启示?可采取哪些措施来管理和影响患者的期待值?这是现代医院管理者普遍面临的一些很棘手的问题。
    医患关系的改变必须引起我们思维观念的改变，从而制定相应的措施。
What kind of influence is medical treatment reformed and be produced to the hospital? How the hospital should do after China join World Trade Organization? Constant changes have role where enlighten patient? Does it manage and influence the patient's expected value which measures are taken? This is some very thorny problem that a modern hospital administrator faces generally.
Changing relationship between patient and hospital cause us thinking the changes of idea and thus make the corresponding measure.

    有疾病，就有病人；有病人，就有医生----医生和病人原本就是一个协同体，而不是对立面，疾病才是他们的共同敌人。医患双方就这样被牢牢地拴在一起，共同托起健康和生命的希望。
There are diseases, there are patients; there are patients, there are doctors ----The doctor and patient are originally one in coordination with body, but not opposite, the disease is their common enemy. Patient & hospital both sides are fastened together firmly held up the hopes of the health and life together.

 

体制改革对医疗市场的巨大影响
The tremendous influence to the medical market of system reform
    计划经济体制下建立起来的卫生管理体制、服务体系和机构运行机制，在市场经济体制下日益暴露固有的弊病，严重制约着我国医药卫生事业的进一步健康发展。如果说20世纪80年代卫生改革面临的是医疗服务供给不足、医疗机构活力不够的问题，那么现在面临的是体制、机制、结构上的重大调整涉及卫生管理体制、服务体系、资源配置结构、机构运行机制等深层次的问题。医疗保险改革的目的，是通过建立适应社会主义市场经济的一系列新的机制和规则，更好地保障人民健康。城镇职工基本医疗保险制度和医药卫生体制改革的总体目标是：用较低廉的费用提供较优质的医疗服务，努力满足广大人民群众基本医疗服务的需要。医疗保险改革的建立允许就诊者自主选择保险定点机构。
Set up hygiene management system, service system and organization operating mechanism under planned economic system, expose the intrinsic disadvantage day by day under the market economic system, is seriously restricting the developing in a healthy way further of medical and health cause of our country. If the hygiene reform faced in the eighties of the 20th century it was the problem that the medical care was supplied insufficiently, medical organization vigor was not enough for, Getting more present so ones that faces for system, the great adjustment on the mechanism, structure involves profound questions, such as management system of the hygiene, service system, resource distribution structure, operating mechanism, etc. The purpose of the medical insurance reform is through setting up a series of new mechanism and rule which meet socialist market economy, using the relatively cheap expenses and offer the relatively high quality medical care to ensure the people to be healthy better.  The setting-up person who allows to go to a doctor of the medical insurance reform chooses the organization by fixed position of the insurance on one's own.

    中国加入世界贸易组织，意味着有多种成分进入中国的医疗市场，参与竞争，迫使医院走向“国际化”，残忍的市场竞争将把一些缺乏活力、医疗技术水平低或服务质量差的医院淘汰出局。老百姓可以选择更高水平的医疗服务，也能选择更多层面的医疗服务——医疗资源的丰富，不再是所有人只拥有一种服务，而是所有人都有选择医疗服务的机会，所有人都有适合于自己的医疗服务。一项由中央新闻单位组织的读者问卷调查表明，有82.1％的人赞成就诊者选择医生的制度。随着经济的发展，人民物质文化生活水平的改善，生物—心理—社会医学模式的转换，人们健康观念的变化，人口老龄化的加快与独生子女的增加，以及医疗消费支付能力的提高，医疗服务的多层次性日趋凸显和丰富，与此相适应，医疗市场的进一步开放，将有利于满足社会不同层次的医疗服务需求。
China joins World Trade Organization means that there are medicals market that many kinds of composition enter China, participating in the competition, force the hospital to move towards" internationalization", it is poor that the cruel market competition will lack vigor, medical technology of some or the hospital in poor service will be eliminated out. Common people can choose the medical care of higher level, can choose the medical care of the stage construction too. The abundance of medical resources is no longer the owner that only has a kind of service, it is all people that have a chance to choose medical cares, all people are suitable for one's own medical cares. A questionnaire investigation of reader organized by central news unit indicates, there are 82.1% of the persons who agrees to go to a doctor of person choose the doctor's system. With economic development, the improvement of people's culture and living standard, the transformation of the living beings - psychology - social medical science mode, the change of health ideas of people, quickening of aging population and the only-child's increase, and consume the improvement of purchasing power in medical treatment, the multi-level quality of the medical care is becoming more protruding and apparent and abundant. In conformity with this, the further opening of medical market will help to satisfy the medical care demands of the social different levels.

    另外，伴随医改的出台，国家对医疗服务取消政府定价，其服务价格实行政府指导价和市场调节价,出现了非营利性医疗机构与营利性医疗机构之分。医院市场营销是现代医院必须具备的重要职能，只有通过市场营销才能体现出医院存在的社会价值。市场营销在很大程度上决定着医院的生存和发展。无论是营利性医院还是非营利性医院，只有通过有效的市场营销活动，才能在竞争激烈的医疗市场上立于不败之地。
In addition, following the appearance of medical reform, the country cancels and valorize to the medical care, its service price implements government's guiding prices and price decided by market demand, the differences of the non-commercial medical organization and commercial quality medical organization have appeared. Marketing modern important functions who hospital possesses hospital, embody and produce social value who hospital have through marketing only. Marketing modern important functions who hospital possesses hospital, embody and produce social value who hospital have through marketing only. The marketing is determining the existence and development of the hospital to a great extent. No matter the commercial quality hospital or the non-commercial quality hospital, only pass the effective marketing activity, Could establish in an unassailable position on the medical market with keen competition.

    国有医疗机构在这种变化的形势下，要实现一个根本性的转变——在相同的“游戏规则”下，变被动为主动，创造好的经营理念和服务模式，争取在激烈的竞争环境中，站稳脚跟，并力图抢占最大的市场份额，实现效益最大化。在这样的形势下，国有医院一方面要进一步提高各种硬件设施，同时还要不断提高医生们的医疗质量。目前，后者更显重要。这就技术和服务。然而，目前大部分医务工作者没有把注意力放在服务质量的改善上。
State-run medical organizations under the situations of change, realize a fundamental transition —under the same game rule, regain the initiative, create the good management theory and service mode, try to stand firm , and try hard to seize the greatest market share in the keen competition environment, Realize that benefit are maximized. Benefit is maximized under such a situation; the state-run hospital should improve various kinds of facilities of hardware further and will improve the doctors' medical quality constantly at the same time. At present, it is important that the latter shows even more，that is medical technology and service. However, most medical stuff does not put attention in the improvement of the service quality.

 

患者不可以简单地等同于消费者
The patient cannot equate with the consumer briefly
    无庸质疑，医患关系是一种合同关系，但它是一种特殊的合同，如果把患者简单地等同于消费者来看，医院的产品和服务就应该符合一定的标准，并对此提供一定的保证——就像很多商品都有“三包”一样。但这是很困难的，因为医生对于治疗的后果是难以准确预料的。事实上很多治疗手段并不能使疾病根治，也不能阻止它复发，这样患者就可以不付钱，或者向医方索赔，显然这是不公平的。
Not needed to query, it is a kind of contract relation between patient & hospital, but it is a kind of special contract. If equating patient with consumer briefly, the hospital must offer certain assurance to them, liking goods guarantee. But this is very difficult for the hospital to do that. The doctor is difficult to expect disease consequence. In fact，a lot of treatment means can not make the disease effect a radical cure , and can't prevent it from recurring either. In this way，the patient needn't pay? Or claim to the hospital? Obviously this is unfair.

举证倒置引起的思考
Put the thinking caused in inversion to the proof
    通过立法来规范医疗纠纷解决的全过程，解开医疗纠纷的“结”，从而让医患双方心服口服，已经是形势的迫切要求。医疗纠纷举证责任倒置就是指当患者将医院推上被告席时，首先要由医院证明自己没有发生医疗过错。如果医院拿不出证据，法院将判医院败诉，并赔偿患者损失。
    医生会否因此见死不救呢？所有纠纷都由医院“举证”，举证的困难必然导致医生的自我保护行为。为了保险起见，医生为病人治疗的时候必然会完全按医书所述进行，因为这样比较保险，出了事有书为证。但事实上很多的临床治疗如果全按医书操作，绝对是救不了病人的。这样一来，最终受害的还是病人。
有行内人士也指出，“举证倒置”实施后，很可能会打击医生勇闯“治疗禁区”的积极性。以前提倡“只要有1％的希望都要用100％的努力来争取”，但现在为了1％的希望，医生要承担99％被告上法庭的风险，这种情况下，不少医生都会选择明哲保身，手术没把握成功就干脆不做了。
    “倒置”会否激化医患矛盾？“倒置”在某些方面免除了患者的责任，可能会导致医疗诉讼剧增，医院难以招架；医学是在探索中不断前进的，对某些未知的疾病，医疗机构难以找到证据来免除自己的责任；一些患者不配合治疗，故意隐瞒病史或叙述不清，结果造成误诊，但医院却要承担责任；取证需要病人配合，而且不同条件的医院取证各有难度。总之，有理由担心举证新办法会激化医患矛盾，给医生带来巨大的精神压力。
    医院应该怎么办？关键问题是要转变心态，要主动适应我国法律制度的完善，跟上历史发展的步伐。针对医疗机构承担的举证责任，为了预防和及时妥善处理医疗侵权纠纷，医疗机构必须制定一系列保障措施。
    另一方面，造成医患之间关系紧张，相互不信任的一个根本原因就是长期以来在医疗制度上形成的不公开、不公平的作法。不公开的表现方式很多，其中比较突出的是收费不公开、治疗手段不公开、医护人员的能力水平不公开。难怪有些患者戏称自己一走进医院就有一种“人为刀俎，我为鱼肉”般“暗无天日”的感觉。当然这种说法未免有些夸张，可它至少表达了一种情绪。
    在公平的问题上患者一样感到悲哀。它表现在当患者对自己的治疗发生疑问的时候，没地方找到一个公平的鉴定机关给自己一个公平的鉴定结论。“老子”给“儿子”作鉴定即使是公平，你愿意相信吗？你又怎么去说服别人相信？
    医院的确是一个特殊的部门，它的特殊性不是表现在可以任意处置患者的医疗档案上，而在于它需要对人给予更大的理解、关怀与尊重，它需要一批更文明、更善良、更有责任感的从业人员。80年代出台的这部医疗法规的确存在着很多的问题亟需廓清，当我们的法律越来越多地倾注进了人文关怀的时候，医疗法规的制定与修改也就越发迫切了，千万别让我们的医院成为社会追求公开与公正的最后一个需要攻破的堡垒。
    不妨制订这样一个条例，明确责任与权利，使医患关系走入良性循环。同时，下大力气提高医生的职业道德水平，让所有的医院进入市场，大浪淘沙。医院要加强与媒体的沟通，通过宣传，让社会了解医疗服务的特殊性、高风险性，增进广大群众对医院的了解。最重要的是医院和医务人员应当加强自律，医院应当依法治院，医务人员应当依法执业，遵守职业道德，尊重并维护病人的合法权益，向他们提供可信赖的医疗服务。