September 2020, Volume 23,No25 Abstracts(A)

Mechanism of Apportionment of Liability and Malpractice Risk Prevention and Control in Delivering Community Health Services MA Yong,ZHANG Xiaolin*,ZHANG Jing,MA Chunxiao,WANG Hongjing
School of Management,Weifang Medical University,Weifang 261053,China
*Corresponding author:ZHANG Xiaolin,Lecturer;
【Abstract】 The mechanism of apportionment of liability and malpractice risk prevention and control is an important guarantee for the effective operation of community healthcare system. In terms of addressing malpractice,medical institutions are the major liable party and malpractice insurance agencies are the secondary liable party for punitive damage compensation according to according to the legislation of private law in China. And community health organizations are facing many difficulties in malpractice risk control and prevention. We summarized the problems of apportionment of liability,and malpractice risk control and prevention faced by community health organizations on the basis of analyzing 481 judicial cases during 2007 to 2019,and concluded that the operation of community healthcare system is confronted with various malpractice risks and lacks of malpractice risk-sharing mechanism at the government level as well as special considerations for malpractice risk sharing in policy making,and punitive damage compensation paid by the medical liability insurance program is difficult to address all risks. To solve the problems,we put forward the following recommendations:adding government liability for malpractice in community health organizations,developing a precise malpractice risk prevention and control system and using multidisciplinary care.
【Key words】 Community health services;Health policy;Risk prevention and control;State supplementary responsibility;Responsibility sharing;Liability insurance
Health Poverty Characteristics and Influencing Factors of Middle-aged and Elderly Patients with Chronic Respiratory Diseases from the Perspective of Poverty Reduction by Medical Insurance MA Meiyan1,LI Ye1*,WANG Nianshi1,WU Qunhong1,JIAO Mingli1,SHAN Linghan1,YANG Huiying2,LIU Limin2,TIAN Wanxin1,XIA Qi1,HAO Yanhua1,LIANG Libo1,GAO Lijun1,NING Ning1,SUN Hong1,KANG Zheng1
1.School of Health Management,Harbin Medical University,Harbin 150086,China
2.Medical Records Room,the Second Affiliated Hospital of Harbin Medical University,Harbin 150001,China
*Corresponding author:LI Ye,Associate professor,Master supervisor;
【Abstract】 Background The chronic respiratory disease(CRD) has become one of the major chronic diseases affecting the health of middle-aged and elderly people in China. The long-term medical expenditure causes a huge economic burden on the elderly and their families,increasing the risk of falling into poverty. In the context of the universal coverage of medical insurance,whether the existing medical insurance system has effectively alleviated the disease burden of patients with CRD and reduced the risk of poverty caused by diseases has become a public concern on the sustainable development of society. Objective To systematically identify and analyze the vulnerable characteristics and influencing factors of middle-aged and elderly patients with CRD,the high-risk group of health poverty,through multi-dimensional analysis. Methods Using the microdata from 2015 China Health and Retirement Longitudinal Study(CHARLS),920 households(2 106 cases) of middle-aged and elderly patients with CRD were investigated. The methods recommended by the World Health Organization were adopted to calculate the catastrophic health expenditure(CHE)and the impoverishment by medical expenses(IME). The influencing factors were analyzed by multivariate Logistic regression. Results The overall CHE incidence rate was 20.65%(190/920) and the IME incidence rate was 7.83%(72/920). The incidence rate of CHE was highest in families with more than 3 kinds of chronic diseases at 44.00%(11/25). There were significant differences in the incidence of CHE among heads of household with different gender, education level,self-rated health status, whether there were inpatients in the family,and other chronic diseases.Multivariate Logistic regression analysis results showed that female heads of households,high school or above,having inpatient family members,combined with more than 3 types of chronic diseases,and uninsured households were the factors affecting the high incidence of CHE(P<0.05). Conclusion The lack of health ability combined with multiple health vulnerabilities,such as hospitalization and chronic diseases,aggravates the risk of CHE among patients with CRD. The existing medical insurance system only guarantees the right of elderly CRD patients to obtain medical resources,but it lacks the system tilt for uninsured households and insured households in new rural cooperative medical system,and accurate identification of the poor among CRD patients. Moreover,it is necessary to further strengthen the depth and range of medical insurance coverage for groups with high utilization rate of health services. The coordination and unification of multi-path health protections such as basic medical insurance,critical illness insurance,medical assistance,and emergency medical assistance should be promoted.
【Key words】 Chronic respiratory disease;Medical insurance;Health poverty;Catastrophic health expenditure;Impoverishment by medical expenses;Root cause analysis
Advances in Supply-demand Study of Contracted Family Doctor Services in China JING Rize1,FANG Hai2*
1.School of Public Health,Peking University,Beijing 100191,China
2.PKU China Center for Health Development Studies,Beijing 100191,China
*Corresponding author:FANG Hai,Professor,Doctoral supervisor;
【Abstract】 The implementation of contracted family doctor services is an important means to promote the development of hierarchical medical system,an important task to deepen the reform of pharmaceutical and healthcare system,and a key way to better safeguard the health of the people under the new situation. We overviewed the advances in supply-demand study of contracted family doctor services in China,with a summary of demand-based study centering on the service delivery status,contacting rate,contract renewal rate,and residents' intention to contract the services,and their awareness of and satisfaction with the services,and supply-based study focusing on the constituent,fostering and educating of service providers(family doctor team),and incentive mechanism for them as well as their job satisfaction,and summarized that most evaluation studies of implementation effectiveness of the services mainly from the demand perspective. Moreover,problems in the research process were analyzed,and future research directions as well as policy recommendations were put forward. In addition,we concluded that there is a research gap in empirical studies of the service delivery from the supply side,and put forward that it is particularly important to further promote the development of contracted family doctor services via improving the training and education and incentive mechanism for family physicians,and the composition of a family physician team.
【Key words】 Family physician;General practitioner;Contracted family doctor services;Perspective of supply and demand;Review
Contracted Family Doctor Service Models Leading to Healthy China:a Comparative Study LIU Rui1,YANG Danhong1*,WU Huanyun2,LI Guofeng2
1.Shanghai Jinshan Industrial Zone Community Health Service Center,Shanghai 201506,China
2.Health Affairs Center of Jinshan District,Shanghai 201540,China
*Corresponding author:YANG Danhong,Chief physician;
【Abstract】 The contracted family doctor service is the focus of China's current medical and health reform. It is an important way to implement hierarchical diagnosis and treatment,achieve rational use of medical resources,and safeguard the health of people. It is also the cornerstone of achieving the Healthy China 2030 Strategy. This paper analyzed six service models of family doctors in China,including "1+1+1" service model in Shanghai,"Three-in-one" service model in Xiamen,family-based integrated medical care service model in Hangzhou,"Prepayment by Per Capita Budget" service model in Dingyuan County,"Basic Package + Individual Package" service model in Dafeng District of Yancheng,and service model in Luohu of Shenzhen. Then this paper compares the subject,method,content,form of the medical treatment alliance,payment of contracted service fees,characteristics of medical insurance payment,analyzes the policy logic and the bottlenecks in the current contracted family doctor service models,and proposed two representative ideal models in urban and rural areas in order to provide reference and inspiration for promoting contracted family doctor services in various areas.
【Key words】 Contracted family doctor services;Service model;Hierarchical diagnosis and treatment
Family Physician Assistants in the Family Physician Team: a Sino-foreign Comparative Analysis HUANG Wuquan,FAN Xiaoye*,ZHAI Jiayi,LU Juping
Jiading Subdistrict Community Health Center,Shanghai 201899,China
*Corresponding author:FAN Xiaoye,Attending physician;
【Abstract】 Background During accelerating the implementation of family physician services,the efficiency of family physicians may be enhanced by the help from an allocated assistant,a role commonly referred to as family physician assistant. Community health centers in some regions of China,such as Shanghai and Beijing,have developed a healthcare delivery mode with family physicians as the core workforce and the main subject of liability,and nurses as major assistants. However,there is still a lack of uniform standard for the constituents of the core workforce of family physician teams,as well as the features,work scope and salary system of family physician assistants. Objective To perform a sino-foreign comparative analysis of family physician assistants,providing a reference for the development of this occupational group in China. Methods From November 5 to 20,2019,we searched the databases of PubMed,ScienceDirect,CNKI and WANFANG DATA for articles involving family physician assistants published between 2009 and 2019 using subject headings or key words such as "amily physician assistant" "general practitioner assistant" "全科医生助理" "家庭医生助理" or "家庭医生 and助理" or "全科医生and助理". Data about staffing allocation,features,major responsibilities and duties,performance assessment and performance-based remuneration allocation of family physician assistants were extracted and analyzed using bibliometric analysis,and were summarized. Results By reviewing the full text,47(31 in English and 16 in Chinese) were found to be eligible. The role of family physician assistant mainly played by full-time physician assistant,nurse,public health physician,rural physician,and general practitioner assistant fostered by a "3+2" general practitioner training program. The difference is that,the position at abroad is held by those who have received pre-service physician assistant training,and obtained the practicing certification or academic credentials,but in China,the full-time position is held by mainly physician assistants of non-medical majors after receiving pre-service family physician assistant training,and the part-time positions,such as nurses,public health physician,and rural physician,are held by incumbent healthcare workers from the community health center. The responsibilities and duties of family physician assistants differ in different countries,but mainly include delivering therapies,health management,health education,triage,preliminary health assessment and chronic disease follow-up. The performance of the family physician assistant is commonly assessed by the healthcare institution using a uniform system,or assessed directly by the family physician at abroad,while in China,that is assessed by institutional uniform assessment,or a two-level assessment,namely,the quality of services included in the whole tasks of the community health center is assessed the quality-control department of the center using a uniform system,and the quality of family physician services is assessed the family physician. Conclusion Great differences have been found between foreign countries and China in terms of occupational aptitudes,major responsibilities and duties,performance assessment and performance-based remuneration allocation of family physician assistants. In view of this,it is suggested to develop the family physician assistant team with general practitioners and nurses/rural physicians or general practitioners and full-time physician assistants as the core workforce,define the responsibilities and duties for family physician assistants multi-levelly,and formulate a remuneration allocation system based on three major indicators,complexity of medical techniques,and quality and quantity of services.
【Key words】 General practitioner assistant;Service mode;Literature review;Personnel allocation;Service content;Performance allocation
Choice of Medical Treatment Institutions and Its Influencing Factors for Patients with Multiple Chronic Diseases:a Study Based on Anderson's Model WANG Pei,LIU Junjun*
Graduate School,Nanjing University of Chinese Medicine,Nanjing 210023,China
*Corresponding author:LIU Junjun;
【Abstract】 Background In recent years,the epidemic of multiple chronic diseases is serious. Exploring the choice of medical institutions and influencing factors in multiple chronic disease patients helps to guide them seeking healthcare in an orderly manner,which eventually promotes the formation of an orderly pattern of healthcare seeking and optimization use of medical and health resources. Objective To investigate the choice of medical institutions and influencing factors in multiple chronic disease patients,providing a reference for promoting the implementation of hierarchical medical system and rational allocation of health resources. Methods This study was conducted from August to November 2019 based on Anderson's behavioral model. Participants(n=666)were adults with at least two chronic diseases selected from the sample of 2016 Chinese Family Panel Studies. A multivariate model was used to identify the influencing factors for the choice of the medical institutions,with variables incorporated,including predisposing factor(sex,age,marital status,education level),enabling factors(hukou,number of family members,annual income,medical insurance,caregivers,satisfaction with the visited healthcare setting,self-rated therapeutic level of the visited healthcare setting),and need factor(self-rated health,change in health after treating,cause of hospitalization and prevalence of two-week discomfort). Results Among the participants,the ratios of seeking healthcare in a general clinic,community health station or village clinic,community health center or township hospital,specialty hospital,and general hospital were 12.5%(83/666),10.7%(71/666),15.6%(104/666),8.7%(58/666),and 52.6%(350/666),respectively. The choice of healthcare setting varied significantly by age,hukou,number of family members,annual income,medical insurance,self-rated therapeutic level of the visited healthcare setting,and cause of hospitalization(P<0.05). Multivariate Logistic analysis showed that predisposing factor(age),enabling factors(hukou,number of family members,annual income,medical insurance,self-rated therapeutic level of the visited healthcare setting),and need factor(cause of hospitalization)were associated with the choice of healthcare setting(P<0.05). Conclusion To satisfy the healthcare needs of multiple chronic disease patients,regional health planning should be improved,and reasonable allocation of health resources should be promoted by grid division of serving area. Moreover,to attract them seeking first-contact care in primary healthcare settings,the service quality of such institutions should be improved,and their service delivery patterns should be actively changed to be more efficiently. Furthermore,the medical insurance for such patients should be expanded,and a complete and multi-level social insurance network for low-income and key groups should be formed. In addition,to promote the implementation of hierarchical medical system,related education should be publicized more intensively to form a scientific way of seeking healthcare instead of only seeking healthcare in large and higher level hospitals.
【Key words】 Multiple chronic diseases;Medical institution selection;Anderson model;Root cause analysis
Frequent Attendance and Effectiveness of Related Interventions in Primary Care JI Yan,DING Jing*,DING Lan,LIU Meixing
Yuetan Community Health Center,Fuxing Hospital,Capital Medical University,Beijing 100038,China
*Corresponding author:DING Jing,Chief physician,Associate professor,Master supervisor;
【Abstract】 Frequent attendance is a well-known phenomenon in primary care caused by physical illness,mental illness and social difficulties,which probably leads to inappropriate use of community medical resources and imposes increased burden on general practitioners and the society, but can be reduced by clinical interventions.This article reviews the current status and influencing factors of frequent attendance as well as the effectiveness of related interventions in primary care,in order to provide a basis for reducing unnecessary frequent visits and making more reasonable use of community medical resources.
【Key words】 Primary health care;Frequent attenders;Root cause analysis;Intervention program;Intervention effects;Review
An Investigation of Factors Affecting Patients' Intention of Online Continuous Consultation and Offline Visiting in eHealth CHEN Jiahe1,MA Jinlu2,ZHANG Yuwei2*
1.Department of Computer Science,Hong Kong Baptist University,Hong Kong 999077,China
2.College of Economics & Management,China Jiliang University,Hangzhou 310018,China
*Corresponding author:ZHANG Yuwei,Associate professor,Master supervisor;
【Abstract】 Background With the flourishing development of Internet technologies,the scale of eHealth consumption expands sharply. Patients' health not only depends on participating in emerging eHealth but also further offline diagnosis and treatment in hospitals. However,the bulk of previous studies on eHealth have merely focused on patients' online counseling intention but have ignored the role of behaviors in offline hospitals.  Objective Integrating justice theory and S-O-R model,this study aimed to investigate the factors affecting patients' continuous intention to consult online and intention to visit offline,in order to provide a comprehensive understanding of the role of doctor-patient interaction in patients' online and offline behaviors as well as the relationships between patients' online and offline behaviors. Methods Based on justice theory,patients' perceived trust was divided into four dimensions:distributive justice,procedural justice,interpersonal justice and informational justice. Based on S-O-R model,patients' perceived justice was characterized as stimulus(S),trust was characterized as organism(O),and continuous intention to consult and the intention to visit offline hospitals were characterized as responses(R). Then a structural equation model was constructed and developed in accordance with the following hypotheses:H1——distributive justice is positively related to perceived justice;H2——procedural justice is positively related to perceived justice;H3——interpersonal justice was positively related to perceived justice;H4——informational justice is positively related to perceived justice;H5——perceived justice is positively related to trust;H6——trust is positively related to continuous intention to consult online;H7——trust is positively related to the intention to visit offline;H8——continuous intention to consult online is positively related to the intention to visit offline. From April to May 2018,with the help of 10 doctors,800 patients who ever received online consultation services delivered by them in were selected and were surveyed using questionnaires developed by our research team for collecting their demographic information and factors associated with online and offline consultations. Subsequently,the measurement model and structural model were examined. Results A total of 284 cases(35.5%)returned responsive questionnaires,with a response rate of 35.5%. And analysis of their survey results showed the measurement model's convergent validity:the factor loadings of items were from 0.81 to 0.92;Cronbach's α was 0.84 to 0.92;composite reliability was 0.90 to 0.94;average variance extracted(AVE)was 0.76 to 0.83. Discriminant validity:the square roots of AVE for each construct exceeded the correlations of other constructs. Distributive justice(β=0.265,P<0.001),procedural justice(β=0.198,P<0.001),interpersonal justice(β=0.275,P<0.001),and informational justice(β=0.378,P<0.001)positively affected perceived justice,supporting the 1st,2nd,3rd,and 4th hypotheses. Perceived justice(β=0.846,P<0.001)positively affected trust,which also explained 71.4% of the variance,supporting the 5th hypothesis. Trust(β=0.593,P<0.001)positively affected continuous intention to consult online,which also explained 34.9% of the variance,supporting the 6th hypothesis. Trust(β=0.368,P<0.001)positively affected the intention to visit offline,supporting the 7th hypothesis. Continuous intention to consult online(β=0.411,P<0.001)positively affected the intention to visit offline,which also explained 47.9% of the variance,supporting the 8th hypothesis. Conclusion By integrating justice theory and S-O-R model,this paper validated patients' perceptions of justice significantly affecting the trust towards doctors,which in turn have the positive influence on patients' continuous intention to consult online and intention to visit offline hospitals.In addition,patients' continuous intention to consult online has a direct impact on the intention to visit offline hospitals.
【Key words】 Telemedicine;eHealth;Health care rationing;Perceived justice;Patient's trust;Continued intention to consult online;Intention to visit offline
Implementation Effect of Hierarchical Medical System in Minhang District,Shanghai XU Chengyan1,HUAN Hongmei1,CHENG Jia2,HANG Wenquan2,MA Yingzhong2*
1.Minhang District Gumei Community Health Center,Shanghai 201102,China
2.Minhang Health Commission,Shanghai 201199,China
*Corresponding author:MA Yingzhong;
【Abstract】 Background To further advance the reform of the pharmaceutical and healthcare system,and improve the healthcare delivery system in Minhang District,Minhang District has embarked on a pilot comprehensive reform of community healthcare system since 2015,which has laid a foundation for the progressive implementation of hierarchical medical system. Objective To analyze the implementation results(including achievements and problems)of a pilot comprehensive community healthcare reform in Minhang District from 2017 to 2018,providing evidence and recommendations for developing a scalable community healthcare evaluation system and for improving the hierarchical medical system. Methods From 2017 to 2018,the 2018 annual evaluation scores of comprehensive community healthcare reform of Shanghai's 16 districts were collected through Shanghai Cloud Management Platform of Comprehensive Community Healthcare Reform,the implementation of contracted services,and workload of community hospitals and higher level hospitals in Minhang District in 2017—2018 during the reform were obtained by reviewing the 2017—2018 Analytical Report on Minhang District Healthcare Institutions Core Data and 2017—2018 Weekly Reports on the Operation of Minhang District Community-based Healthcare Management Platform issued by Minhang District Public Healthcare Institutions Management Center,and data about bi-directional referrals and technical assistance for community hospitals offered by higher level hospitals within Minhang District medical consortiums during 2017—2018 were gathered from Minhang District Health Commission's Reports on Medical Affairs Core Data and Reports on Medical Consortium Core Data. Results The top three districts with highest 2018 annual evaluation scores of comprehensive community healthcare reform were Jinshan District〔(76.88±3.67)points〕,Minhang District〔(76.78±2.50)points〕,and Songjiang District
〔(76.06±2.16)points〕,while the bottom three were Yangpu District〔(58.71±3.65)points〕,Huangpu District〔(53.68±2.45)points〕,and Changning District〔(37.61±17.60)points〕. The losing items for Minhang District mainly fell on such three indicators as the coverage of contracted services,the flow of consultations and the costs per consultation.Compared with 2017,in 2018,Minhang District obtained higher rate of signing "1+1+1" type contracted services,and higher percent of contracted residents over 60 years,but less average visits per capita,less average outpatient healthcare cost per capita,lower rates of visiting the contracted community hospital and the contracted hospitals,as well as lower rate of seeking healthcare and having extended prescriptions in non-contracted hospitals in contracted residents(P<0.05). And compared with 2017,the year 2018 in Minhang District saw a rise of 0.99% of outpatient/emergency visits and 6.55% of inpatients at higher level hospitals,while at the community level,outpatient visits fell 1.32%,and inpatients rose 0.25%. The number of long-term prescriptions for chronic diseases increased by 7.58% with its accounting proportion up by 5.25%,and the number of extended prescriptions increased by 33.95% with its amount up by 86.42%. And the number of upward referrals rose 709.70% while that of downward referrals fell 35.34%. Experts introduced to the district medical institutions from higher-level hospitals in the medical consortium increased by 13.92%. The number of technical guidance provided by higher-level hospitals to the communities rose 4.87%. The number of persons sent from the communities to higher-level hospitals for further studies and trainings was up by 16.35%. And the number of remote community consultations conducted by higher-level hospitals via picture archiving and communication system increased by 1.32%,while that via Medigus Ultrasonic Surgical Endostapler system rose 10.91%. Conclusion In 2018,Minhang was in the high-rankings in terms of the annual evaluation score of comprehensive community healthcare reform. The rate of contracting services increased significantly and contracted residents' visits and outpatient costs were effectively controlled. The number of long-term and extended prescriptions increased remarkably and community visits decreased,and the number of experts introduced to the community level,bi-directional referrals and the technical assistance offered by higher-level hospitals to communities increased sharply within the regional medical consortium. Generally,the pilot comprehensive reform of community healthcare system has achieved prominent effects,providing evidence for the establishment of a scalable evaluation system and for the improvement of the hierarchical medical system. However,there are still problems such as inadequate flow of consultations and poor downward transfers,and the like. Therefore,further work for bi-directional referrals is needed.
【Key words】 Hierarchical medical system;Community health services;Comprehensive reform of community health service;Shanghai;Medical consortiums
Early Renal Damage in Obese Hypertensive Patients:Prevalence and Influencing Factors HUANG Sulan,LIANG Li*,GE Liangqing
Cardiovascular Department,the First People's Hospital of Changde City,Changde 415000,China
*Corresponding author:LIANG Li,Associate chief physician;
【Abstract】 Background The risk factors associated with microalbuminuria in patients with obesity-related hypertension have been less studied except obesity. Objective To investigate the prevalence and related risk factors of early renal damage in newly diagnosed obese hypertensive patients. Methods From December 2015 to December 2017,a total of 456 newly diagnosed hypertensive outpatients from the First People's Hospital of Changde City were enrolled,including 111 with obesity,210 with overweight,and 135 with normal weight. The general demographic data,renal function indices,clinical blood pressure and ambulatory blood pressure as well as early renal function impairment were analyzed according to weight status.Then,a comparative analysis of clinical data of obese patients of MAU positive group and negative group was performed,and risk factors associated with microalbuminuria were identified by multivariate Logistic regression analysis. Results There were significant differences in gender ratio,average BMI,HDL-C,TG,microalbuminuria prevalence,creatinine,uric acid,clinic systolic blood pressure(SBP) and diastolic blood pressure(DBP),24-hour SBP,daytime SBP and DBP,and nighttime SBP in obese,overweight and normal-weight groups(P<0.05). Obese patients with microalbuminuria had higher average levels of fasting blood glucose,clinic SBP and DBP,24-hour SBP and DBP,daytime SBP and DBP,and nighttime SBP and DBP compared with those without;higher rate of decline in nighttime SBP compared with those without(P<0.05). Multivariate Logistic regression analysis showed that fasting blood glucose〔OR(95%CI)=8.289(2.221,30.936)〕,daytime SBP
〔OR(95%CI)=5.528(1.019,30.588)〕 and rate of decline in nighttime SBP〔OR(95%CI)=0.117(0.038,0.360)〕were the influencing factors of microalbuminuria in obese patients with hypertension(P<0.05). Conclusion Obese hypertensive patients are at high risk of early renal damage. Fasting blood glucose,daytime SBP and rate of decline in nighttime SBP are correlated with microalbuminuria.
【Key words】 Hypertension;Blood pressure determination;Overweight;Obesity;Renal damage;Root cause analysis
The COX Risk Prediction Model for Depression in Patients with Chronic Hepatitis B REN Liang,WANG Guixia*,JIANG Na,TANG Wenjun,ZHANG Xingbi
Department of Infectiou Diseases,Affiliated Hospital of North Sichuan Medical College,Nanchong 637000,China
*Corresponding author:WANG Guixia,Attending physician;
【Abstract】 Background Chronic hepatitis B is the most widespread and most harmful infectious disease in China,often accompanied by depression. Patients with mild depression have a depressed mood,and those with severe symptoms have not only aggravated inherent diseases,but may even commit suicide. At present,the commonly used treatment measures have unsatisfactory effects,and active preventive nursing has become the focus among medical staff. Objective To construct a Cox risk prediction model for depression in patients with chronic hepatitis B. Methods A total of 245 patients with chronic hepatitis B admitted to the Affiliated Hospital of North Sichuan Medical College were selected as research subjects from June 2017 to May 2018,and their depression situation were followed up. After the data pre-processing was completed,all factors were conducted univariate analysis and multivariate COX risk factor analysis,and a risk prediction model was constructed. The nomogram was used to show the prediction model,and the receiver operating characteristic(ROC) curve was used to evaluate the model discrimination. The calibration curve was used to evaluate the accuracy of the model,and the clinical decision curve analysis was used to evaluate the validity of the model. Results The results of univariate analysis showed that there were significant differences in the incidence of depression among patients with different ages,occupations,education background,hepatitis B grades,infection time,diagnosis time,recurrence times,family status,marriage satisfaction,fear of difficult to cure the disease,fear of hospitalization environment,disease stage,complications,and confidence in treatment(P<0.05). The results of multivariate COX risk factor analysis showed that RR=-1.446 1×(the occupation is intellectual)-0.688 7×(education background was high school or technical secondary school)-2.043 0×(frequent drinking)-0.783 5×(occasional smoking)-1.068 2×(frequent smoking)-0.894 0×(diagnosis time was 0.5-5 years)-1.092 4×(diagnosis time was less than 0.5 year)+1.335 2×(dissatisfaction with family status)+1.345 1×(dissatisfaction with marriage)-0.574 3×(not worried about unsuitable hospitalization environment). The area under the ROC curve(AUC) of the COX risk prediction model constructed in this study was 0.979 8. The specificity of the model was 0.972 5,the sensitivity was 0.940 7,and the accuracy was 0.954 9. The model had a positive likelihood ratio of 34.180 2,and the negative likelihood ratio was 0.060 9. The diagnostic value ratio was 560.916 7. The positive predictive value was 0.976 9 and the negative predictive value was 0.929 8. The model had great discrimination.In terms of model accuracy evaluation,when the event rate was below 16%,the model overestimated the risk;when the event rate was between 16% and 40%,the model underestimated the risk;when the event rate was between 40% and 80%,the model overestimated the risk;when the event rate was between 80% and 100%,the model underestimated the risk;when the event rate was 16%,40% and 80%,the predicted value and observed value were exactly the same. On the whole,this model had good accuracy. The clinical decision curve showed that the net benefit value was high,which showed the effect of clinical decision-making based on the prediction results of this model could bring great benefit to patient's condition. Conclusion The risk prediction model for depression in patients with chronic hepatitis B constructed in this paper can be used to predict the risk of depression in patients with chronic hepatitis B so as to guide the clinical medical staff to carry out targeted intervention measures,and ultimately avoid or reduce the possibility of depression,which is worthy of clinical application.
【Key words】 Hepatitis B,chronic;Depression;Risk prediction model;Cox regression
Relationships of Insomnia Symptoms with Interoceptive Awareness and Anxiety Sensitivity in Adults with Cardiovascular Disease HUANG Liu,ZHANG Xi,CAI Chunfeng*
Wuhan University School of Health Sciences,Wuhan 430000,China
*Corresponding author:CAI Chunfeng,Co-chief superintendent nurse,Master supervisor;
【Abstract】 Background Sleep disorders can cause cardiovascular diseases(CVD),among which insomnia is one of the most frequently seen. Insomnia is often affected by anxiety,depression and other psychological factors. To be specific,anxiety influences insomnia via anxiety sensitivity,an important intermediary. Moreover,abnormal interoceptive awareness is also closely related to insomnia. To develop interventions for insomnia symptoms based on interoceptive awareness and anxiety sensitivity,besides the evidence from very limited available studies about the correlations of the three factors,studying the associated factors of insomnia symptoms may be used as an additional theoretical assistance. Objective To investigate the relationship of interoceptive awareness and anxiety sensitivity with insomnia symptoms in adult patients with CVD,and based on this,to analyze the predictive value of the former two for the latter,to provide a theoretical basis for the delivery of intervention of insomnia symptoms. Methods A cross-sectional survey was conducted in a grade A tertiary hospital in a city of China. 170 adult patients with CVD were selected by convenient sampling from October to December 2019. The General Information Questionnaire developed by our research group,Interoceptive Awareness Questionnaire(IAQ),Anxiety Sensitivity Index-3(ASI-3) and Insomnia Severity Index(ISI)  were used to investigate. Results A total of 160 valid questionnaires were collected, with an effective recovery rate of 94.1%. 78.8%(126/160) of the participants experienced insomnia,among whom 63(50.0%) had mild insomnia,53(42.1%) had moderate insomnia and 10(7.9%) had severe insomnia. The average scores of IAQ,ASI-3 and ISI for the participants were(55.39±11.58),(34.76±16.35),and(12.36±6.38),respectively. The ISI score changed significantly according to gender and types of CVD(P<0.05). Pearson correlation analysis showed that the severity of insomnia symptoms was linear positively correlated with the levels of interoceptive awareness and anxiety sensitivity(r=0.406-0.554,P<0.05). Multiple linear regression analysis showed that anxiety sensitivity(b=0.216,P<0.001) and interoceptive awareness(b=0.224,P<0.001) were important influencing factors of insomnia symptoms after controlling gender and disease type,explaining 46.3% of the total variance of insomnia symptoms. Conclusion Interoceptive awareness and anxiety sensitivity are important predictors of insomnia in patients with CVD. The use of multimodal psychosomatic intervention may be a future research direction.
【Key words】 Cardiovascular disease;Sleep insomnia and maintenance disorders;Interoceptive awareness;Anxiety sensitivity
Predictive Value of C-reactive Protein to High Density Lipoprotein Cholesterol Ratio and Neutrophil to Lymphoid Ratio in Coronary Heart Disease XUE Yazhi,ZENG Xiaorong,LIN Zixiang,WU Tongwei,GUO Zhigang*
General Practice Training Base,Huiqiao Medical Center,Nanfang Hospital,Southern Medical University,Guangzhou 510515,China
*Corresponding author:GUO Zhigang,Chief physician,Professor,Doctoral supervisor;
【Abstract】 Background The incidence and mortality of coronary atherosclerotic heart disease(CAD) in China are still high. Under the hierarchical diagnosis and treatment system,early and noninvasive assessment of the severity of coronary artery lesions is helpful to reduce complications and improve the prognosis of patients. Objective To explore the value of C-reactive protein to high density lipoprotein cholesterol ratio(CHR) and neutrophil to lymphocyte ratio(NLR) in the diagnosis and prediction of coronary heart disease. Methods A total of 651 patients who underwent coronary angiography for the first time in Nanfang Hospital were selected as the research subjects from January 2014 to August 2018,including 480 CAD patients(CAD group) and 171 non-CAD patients(non-CAD group). Patients in CAD group were divided into acute coronary syndrome(ACS) group(n=306) and stable angina pectoris(SAP) group(n=174) according to clinical classification.The risk factors,blood lipid and inflammatory indexes were compared among groups,and the diagnostic and predictive value of CHR and NLR on CAD was evaluated.SPSS 20.0 statistical software was used to analyze the data and draw the receiver operating characteristic(ROC) curve,and DeLong nonparametric test was used to analyze the predictive value of different indicators for coronary heart disease. Results The difference in CHR and NLR between CAD group and non-CAD group was statistically significant(P<0.05). There was significant difference in NLR and CHR among non-CAD group,ACS group and SAP group(P<0.05),and further comparison results showed that compared with the ACS group,NLR and CHR of non-CAD group and SAP group decreased significantly(P<0.017). The AUC(95%CI) of CAD predicted by CHR was 0.640(0.568,0.712),by NLR was 0.681(0.617,0.745),and by CHR combined with NLR was 0.691(0.625,0.757). The AUC(95%CI) of ACS predicted by CHR was 0.676(0.615,0.738),by NLR was 0.746(0.734,0.829),and by CHR combined with NLR was 0.752(0.697,0.807). Spearman correlation analysis showed that CHR and NLR were positively correlated with the Gensini score(rs=0.163,0.172,P<0.05). Patients in CAD group were divided into high CHR group and low CHR group according to the median of CHR(4.14),and high NLR group and low NLR group according to the median of NLR(3.00). The results showed that the proportion of multivessel lesions and Gensini scores in high CHR group and high NLR group were higher than those of low CHR group and low NLR group(P<0.05). Conclusion CHR and NLR are related to the severity of CAD and the clinical stability of coronary heart disease. The higher the value of CHR and NLR are,the more serious the lesions are and the more likely the unstable events of coronary artery will occur,which can be used as a reference index for the auxiliary diagnosis and condition evaluation of coronary heart diseases. And these indexes are easy to obtain and have important value in the clinical practice of grassroots doctors.
【Key words】 Coronary disease;C-reactive protein;Cholesterol,HDL;Neutrophils;Lymphocytes;Diagnosis
Influencing Factors of Blood Glucose Elevation Rate after 75 g Glucose Load in Newly Diagnosed Type 2 Diabetic Patients LIAO Shibo,HUANG Shuyu,ZOU Yi,WU Min*,YAN Yimin,ZHU Zhao,ZENG Rong,HU Jia,LI Ling,HUANG Gao,XIANG Cheng
Department of Endocrinology,Xiaogan Hospital Affiliated to Wuhan University of Science and Technology,Xiaogan 432000,China
*Corresponding author:WU Min,Chief physician;
【Abstract】 Background Rapid changes in blood glucose can cause damage to tissues and organs of the body,but at present,domestic and foreign scholars generally pay insufficient attention to the rate of blood glucose change. It is of great significance to study the rate and influencing factors of blood glucose change for the prevention and treatment of diabetes complications. Objective To investigate the influencing factors of blood glucose elevation rate after 75 g glucose load in newly diagnosed type 2 diabetes mellitus(T2DM) patients. Methods Participants were 337 initially diagnosed T2DM inpatients who were treated in Department of Endocrinology,Xiaogan Hospital Affiliated to Wuhan University of Science and Technology between January 2016 and April 2019. A retrospective study was preformed on their clinical data,including general demographic information,routine blood test and biochemical parameters,HbA1c,results of a 3-hour 75 g OGTT〔glucose peak value(Gmax),time to peak glucose(Tmax),and mean post-load plasma glucose elevation velocity(Vmean)〕,first-phase insulinogenic index(ΔI30 /ΔG30) measured by insulin response test(IRT),and β-cell function and insulin resistance(IR) assessed by homeostatic model(HOMA). According to Vmean tertiles,participants were divided into low Vmean group(n=112),medium Vmean group(n=112) and high Vmean group(n=113). Logistic regression was used to analyze the influencing factors of post-load glucose elevation rate. Results The age,HbA1c,G120,I120,ΔI30/ΔG30,HOMA-β,neutrophil count,lymphocyte count and serum uric acid differed significantly across Vmean tertile groups(P<0.05). Spearman's correlation analysis showed that Vmean was positively correlated with HbA1c and G120,and was negatively correlated with age,I120,ΔI30/ΔG30 and HOMA-β(P<0.01). Ordinal Logistic regression analysis showed that high ΔI30/ΔG30〔OR=0.758,95%CI(0.662,0.867)〕 and older age〔OR=0.966,95%CI(0.949,0.984)〕 were protective factors associated with Vmean delay,while high HbA1c〔OR=1.138,95%CI(1.011,1.280)〕 was associated with increased risk of Vmean delay(P<0.05). Conclusion Elevated ΔI30/ΔG30,and high HbA1c and older age were associated with plasma glucose elevation velocity after a 75 g oral glucose load in initially diagnosed T2DM patients. In view of this,improving first-phaseΔI30 /ΔG30,and HbA1c control rate should be considered as an important measure to delay the post-load sharp rise in blood glucose in such patients.
【Key words】 Diabetes mellitus,type 2;Glucose tolerance test;Insulin release test;Acute hyperglycemic;Root cause analysis
Clinical Features of Patients with Cervical Cancer Treated by Surgery ZHANG Taohong1,ZHANG Meng2,GAO Li1,XUE Yan1,WANG Lisha1,AN Ruifang1*
1.Department of Obstetrics and Gynecology,the First Affiliated Hospital of Xi'an Jiaotong University,Xi'an 710061,China
2.Office of Medical Information Management,the First Affiliated Hospital of Xi'an Jiaotong University,Xi'an 710061,China
*Corresponding author:AN Ruifang,Chief physician,Doctoral supervisor;
【Abstract】 Background Cervical cancer is one of the malignant tumors of the reproductive tract that threaten women's health. Currently,there are different surgical treatments such as laparotomy,laparoscopy and robot assisted surgery. Previous studies have focused on the effectiveness and safety of various surgical treatments, as well as the types of human papillomavirus (HPV)infection and high-risk factors,but the clinical characteristics of patients with cervical cancer treated by surgery in this area have not been analyzed. Objective To investigate the clinical manifestations and characteristics of patients with cervical cancer treated by surgery. Methods The Data of 776 inpatients who were diagnosed with cervical cancer and surgically treated in the First Affiliated Hospital of Xi'an Jiaotong University from January 2013 to December 2017 were collected. To compare the clinical characteristics of the patients with different age,the place of residence and the blood type. The clinical characteristics of patients in different groups such as marriage age,gravidity,parity,menarche age,primiparity age,reasons for visiting,clinical stages and histopathological types were analyzed. Results The average age of 776 cervical cancer patients was(59.8±9.8)years old,64.4%(500 / 776)of them were from other cities,88.5%(687 / 776) of them were squamous carcinoma,7.3% (57 / 776) of them were adenocarcinoma, the rest were adenocarcinoma and other special pathological types(small cell carcinoma,neuroendocrine carcinoma,etc.). There were significant differences in the gravidity,parity,menarche age,primiparity age,reasons for visiting,clinical stages and histopathological types among patients aged ≤ 35,36-49 and ≥ 50 years(P<0.05),but the marriage age,differentiation of tumor cells,myometrial invasion,vascular invasion and pelvic lymph node metastasis had no statistical significance(P>0.05). There were significant differences in the marriage age,parity,menarche age,and primiparity age among patients in this province,cities outside the province ,and other provinces and cities(P<0.05),while gravidity,reasons for visiting,clinical stage,histopathological types,differentiation degrees,myometrial invasion,vascular invasion and pelvic lymph node metastasis had no significant difference among groups(P>0.05). There was a significant difference in gravidity among patients with different blood types(P<0.05),and there were no significant differences in other clinical factors(P>0.05). Conclusion Patients with cervical cancer undergoing surgical treatment mainly suffer from squamous cell carcinoma. Most of the patients are middle-aged and elderly people from other provinces. In addition,the occurrence and development of cervical cancer is not associated with blood types and regional distribution but it is closely related to age. Therefore,the screening of cervical cancer in the elderly in this region and surrounding areas should be strengthened.
【Key words】 Vterine cervical cancer;Gynecologic surgical pocedures;Clinical characteristics
Application and Evaluation of Standardized General Medicine Residency Training Assessment System JIANG Rui,WANG Yongchen*,JIANG Lihong,MENG Jia,WANG Junying
Department of General Practice,the 2nd Affiliated Hospital of Harbin Medical University,Harbin 150086,China
*Corresponding author:WANG Yongchen,Professor,Master supervisor;
【Abstract】 Background In recent years,the implementation of standardized general medicine residency training in China has achieved initial results. Heilongjiang Province has developed a standardized general medicine residency training assessment system(SGMRTAS),and constantly revised it based on analyzing the problems and summarizing the lessons during 4-year implementation of such trainings,which makes the system increasingly satisfy the training needs of general practitioners in this province. Objective To gradually improve the standardized general medicine residency training assessment criteria and methods by analyzing the problems during the implementation of the SGMRTAS since 2014 and giving countermeasures,to make the system increasingly satisfy the needs of such trainings. Methods We recruited 100 residents who had an experience of participating in the standardized general medicine residency training conducted by the 2nd Affiliated Hospital of Harbin Medical University from September 2014 to May 2019. We counted the annual assessment results of the trainees in the past three consecutive years,and used the Questionnaire on Satisfaction with Standardized General Medicine Residency Training Assessment Methods to measure the trainees' satisfaction with the current SGMRTAS. Results Of the 95 trainees included,41 attended the training in 2015,30 in 2016,and 24 in 2017. The annual assessment pass rates in the past three consecutive years for 2015 and 2016 grade trainees were all 100.0%,including those who failed the first assessment,but passed the make-up assessment. The pass rates for the final test of the training for 2015 and 2016 grade trainees were 88.6%(31/35),and 100.0%(30/30),respectively. The mean scores of 13 items in the questionnaire ranged 2.5-4.0 points. The top two items with the highest scores were "The training helps residents to complete basic clinical skills and practical performance assessment" "The training promotes the culture of residents' clinical thinking",while the two bottom ones with the lowest scores were "The training helps residents to complete scientific research performance assessment" "The training can objectively evaluate the comprehensive capabilities of residents". Conclusion The current assessment system has good feasibility and high acceptance of trainees. To further improve the SGMRTAS,more attention should be paid to the evaluation of residents' scientific research performance and comprehensive capabilities.
【key words】 General practitioners;Education,medical;Inservice training;Educational measurement
Application of Formative Evaluation with DOPS in Graduation Internship in General Practice Department QI Dianjun,ZHU Liangliang,WANG Shuang,YU Xiaosong*
Department of General Practice,the First Hospital of China Medical University,Shenyang 110001,China
*Corresponding author:YU Xiaosong,Professor,Doctoral supervisor;
【Abstract】 Background Direct observation of procedural skills(DOPS) is a formative evaluation tool with teaching function for assessors to provide immediate assessment and feedback through direct observation of students' skills,which can evaluate students' learning process objectively and comprehensively. It is of great significance to introduce DOPS into teaching evaluation of general practice. Objective To discuss the significance and effect of DOPS as formative evaluation tool in graduation internship in General Practice Department. Methods A total of 72 seven-year clinical medical students of Grade 2013 in China Medical University were selected by cluster sampling from September to October in 2018. All students were randomly divided into experimental group and control group with 36 cases in each group by random number table method,and they were assigned to participate in a one-week internship in the General Practice Ward of the First Hospital of China Medical University. After the internship,a one-week clinical practice was conducted.In the control group,the traditional teaching method was used in the training of clinical practice skills.In the experimental group,formative evaluation with DOPS was conducted twice in the one-week course of clinical practice. The two groups were taught by the same teachers. At the end of rotation,mini-clinical evaluation exercise(Mini-CEX),clinical skill operation score,theoretical examination and questionnaire survey were used for teaching evaluation. Results There was no significant difference between the experimental group and the control group in the theoretical test scores(P>0.05). The clinical skill operation scores of the students in the experimental group and the control group were(76.67±6.20) and(72.50±7.66) respectively,and there was a significant difference between the two groups(P<0.05). The Mini-CEX scores of the experimental group were higher than those of the control group in terms of physical examination,humanistic care,communication skills and overall performance(P<0.05). The clinical operation time of DOPS was(11.32±1.76) min,the feedback time was(13.14±2.21) min,and the total time was(24.46±1.97) min. More than 80% of the students thought that DOPS was helpful to discover small problems in their operations and feel the attention and concern of teachers with strong feasibility. It could also improve operational skills and cultivate humanistic literacy and communication skills. Conclusion Carrying out DOPS as formative evaluation tool in graduation practice of General Practice Department could improve students' clinical skills and Mini-CEX scores and improve the teaching effect effectively.
【Key words】 General practice;Process assessment(health care);Formative assessment
Recent Developments in General Practitioners' Competence Evaluation LIU Pingyang,WANG Haitang,DU Zhaohui*
Shanggang Community Health Center of Pudong New Area,Shanghai 200126,China
*Corresponding author:DU Zhaohui,Chief physician;
【Abstract】 The evaluation of general practitioners'(GPs') ability is a systematic project,which plays an important role in the development of general medicine,the construction of GPs team and the progress of community health in China.This paper systematically reviews the similarities and differences of GPs' competence assessment in the United States,the United Kingdom,Australia and Canada,as well as the advantages and disadvantages of the main assessment methods for GPs' competence in China,such as institutional self-assessment,physician performance assessment,professional title assessment and appointment,and regular physician performance assessment,and the research progress in competency assessment,comprehensive ability assessment and clinical ability assessment in China. On this basis,this paper puts forward suggestions for the evaluation of GPs' ability in China:unifying the evaluation standards,standardizing the assessment process;setting reasonable indicators,focusing on empirical research;conducting normal management,dynamic assessment,and scientific assessment. In addition,this paper introduces the TSH(theory-skill-humanity) competence evaluation model proposed by Shanghai Shanggang Community Health Center,which will be an important method for GPs' competence evaluation in line with the general medicine development of China.
【Key words】 General practitioners;Employee performance appraisal;Educational measurement;Community health services;Review
The Establishment and Empirical Research of Beijing Family Doctor Evaluation System by Text Mining Method LIU Fangyu1,ZHAO Jing1*,LI Ze1,HUANG Minting1,ZHAO Bingyuan2
1.School of Management,Beijing University of Chinese Medicine,Beijing 100029,China
2.Graduate School of Beijing University of Chinese Medicine,Beijing 100029,China
*Corresponding author:ZHAO Jing,Associate professor,Master supervisor;
【Abstract】 Background Through the evaluation of the current status and development system of family doctors,it is possible to evaluate and optimize the implementation effect of family doctor policies. Objective To construct a three-level indicator system to evaluate family doctors in Beijing,in order to provide reference for relevant departments in formulating family doctor contracted service policies. Methods From March to April 2019,firstly,the content analysis method was used to analyze the relative policy objectives in Notice on Further Strengthening the Work Related to Family Doctor Contracted Service issued by Beijing Municipal Health Commission(Jing〔2018〕9) to extract the first-level indicators. Secondly,using the text mining method and ROST content mining system,the weight of each indicator was formed through word segmentation processing,term frequency statistics,and word cloud output. Based on the results of the term frequency statistics,the weight of the indicators was determined. Finally,the content of the indicators was adjusted according to the opinions of experts. Subsequently,the family doctor service among four community health service centers in Beijing was evaluated by the empirical method. Results This paper finally built a Beijing Family Doctor Evaluation System consisting of three first-level indicators(service preparation and publicity,service content and process,service supervision and guarantee),seven second-level indicators(service preparation, service publicity,service personnel and process,service content implementation,service improvement,service supervision mechanism and service supporting mechanism) and 23 third-level indicators(with unified service agreement text basic content and format,etc),and the weight ranges of these indicators was formed. This evaluation system was applied to four community health service centers in Beijing,and the scores were all above four points,which was in line with the actual situation. Conclusion The Beijing Family Doctor Evaluation System contructed by text mining method could be used to evaluate the implementation effect of family doctor policies in Beijing.
【Key words】 Family doctor;Index system;Text mining method;Beijing
Personal Development-oriented Comprehensive Ability Evaluation for General Practitioners: a Survey from a District of Shanghai PAN Ying1,2,3,4,CHEN Yuge1,2,3,4,WANG Zhaoxin3,5,YU Dehua1,2,3,4*
1.Department of General Practice,Yangpu Hospital,Tongji University,Shanghai 200090,China
2.Academic Department of General Practice,Tongji University School of Medicine,Shanghai 200090,China
3.Shanghai General Practice and Community Health Development Research Center,Shanghai 200090,China
4.Shanghai General Practice Clinical Quality Center,Shanghai 200090,China
5.School of Public Health,Shanghai Jiao Tong University School of Medicine,Shanghai 200025,China
*Corresponding author: YU Dehua,Professor;
【Abstract】 Background The construction of general practitioner(GP) workforce in China is relatively backward.And insufficient qualified GPs introduced in primary care restricts the increase of primary care quality level. At present,the evaluation of the ability of GPs is mainly based on the six core competencies proposed by WONCA. In China,the research on the evaluation of GPs' ability started relatively late,which mainly focuses on the director of community health center(CHC),community healthcare institutions,clinical ability of GPs,but rarely involves personal comprehensive ability of GPs. Objective To develop a comprehensive ability evaluation system for GPs and test its effectiveness in GPs from a district of Shanghai,providing guidance for the practice of GPs,development of GP workforce and cultivation of outstanding GPs. Methods Analytic Hierarchy Process(AHP) was used to develop a questionnaire named as Comprehensive Ability Evaluation System for GPs.Then the questionnaire was used in a self-administered survey among 48 GPs from 12 CHCs(4 GPs from each) in a district of Shanghai in June 2018 for evaluating their comprehensive abilities. Results  The system measures GPs' comprehensive abilities from four aspects:clinical diagnosis and therapeutic ability,public health service ability,research and teaching ability and humanistic literacy. The survey results showed that the mean overall score of comprehensive abilities for these GPs was 78.25 points,namely,an upper-middle level. Specifically,GPs scored highest in healthy literacy,followed by clinical diagnosis and therapeutic ability,public health service ability,and research and teaching ability. In particular,GPs scored only 54.49 points in scientific and research ability on average,which was the lowest among all item scores. Conclusion The training of GPs must be carried out from multiple perspectives. To improve GPs' comprehensive abilities,inputs on medical,public health,health literacy and scientific and research trainings for them should be increased,with a focus on their weaknesses such as scientific research and teaching.
【Key words】 General practitioner;Comprehensive ability;Talents cultivation;Shanghai


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