How far is the doctor free to flow?

Following the implementation of a multi-practice management practice for physicians in Kunming City, Guangdong Province, and Hainan Province in Yunnan Province, Beijing implemented a multi-point practice system on March 1. In the process of advancing this work in the previous provinces and cities, there have been phenomena such as: "The doctors have reacted poorly, the presidents of public hospitals have not supported, and the 'underground' flows have more than the practice at multiple points". Will these phenomena repeat itself in Beijing? This edition invites several experts to analyze the difficulties and solutions that may be encountered in the current multi-point practice system from different perspectives and levels.

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Why is it more cold to practice? Liao Xinbo, deputy director of the Department of Health of Guangdong Province, lacks quality resources to promote the pace of multiple practice. The relationship between hospitals and doctors in China is one to one. A doctor is a “unit person” who belongs to a hospital. After practicing more points, doctors need to go out and follow patients to become social resources. Some experts believe that from a realistic point of view, the biggest short-term effect of the legalization of multiple practices on doctors is income. Doctors will rely on their own medical skills to gain higher incomes. In my opinion, the purpose of doctors practicing more points is to ease the contradiction between the supply and demand of medical resources. It is also necessary to rationalize the allocation of limited quality medical resources. Solving income is only one aspect. Solving the full utilization of talents and maximizing the use of professionals, equalizing the development of medical services, and rationalizing the flow of talents are important aspects that need attention.

If we look at the current policy of the "large hospital supporting small hospitals" of the Ministry of Health, the multi-point practice policy will also help promote the sinking of quality resources to the grass-roots level and guide more medical personnel to the primary medical institutions. Of course, this requires a series of policy support and financial support.

Whether or not it can be implemented must first solve the deep-seated problems After Guangdong Province has tried more practice, the situation of “media fever and doctors cold” has appeared, and the overall situation has not yet been opened. This situation is estimated to occur in Kunming City and other places in Yunnan Province. why? Because allowing doctors to practice more than just a call, it needs a lot of support.

First of all, we must solve the problem of how the government invests. Today's hospitals have little or no government investment. The management of public hospitals imposes a very large limit on the doctors' multi-practice business. This restriction is not only limited to working staff, but also to retirees. Do not say that flowing between hospitals of different nature, or between hospitals of the same nature and even hospitals within the system, is a huge challenge. The biggest challenge is that public and private hospitals are in the same market environment. Talent mobility means the flow and loss of resources. This resource is talent and technology. Which hospital is willing to lose talent and lose the source? This is one of the reasons why the hospital is getting bigger and bigger.

Now, the personnel system, labor system, and security system make it difficult for doctors to “freedom”. Doctors are also reluctant to lose all kinds of protection within the system for “freedom”. I think that the more it is this time, the more we should fully open up and practice more, and now is the best time to push forward with more practice.

The second problem is the legalization of part-time work. Many national laws provide that the government (hospital) personnel cannot part-time. Therefore, there must be a legal support environment to implement more practices.

To completely emancipate the mind to allow doctors to be free people, I believe that the current practice of multiple points of practice does not completely emancipate the mind. Suggestion: All practicing doctors who have undergone standardized training and are registered locally can practise more with the employer’s consent and contractual protection. Through legal constraints, contractual constraints instead of administrative constraints. At the same time, the processing of multiple points of practice does not require the consent of the original employer, because it is possible to have multiple approval points for the practice in the administrative department, and agree not to rely on the hospital's employment contract. In fact, there are more "underground" flows than legal flows, and local multi-point practice has not played an active role.

In addition, I think that the limitation of the title is unreasonable, and the useful talents are not necessarily those who have professional titles. In terms of job titles, people cause “discrimination” and they will stifle the enthusiasm of doctors.

To achieve truly multi-practice practice, we must refer to international practices and let doctors become truly freelancers, through contracts and legal restrictions.

It is recommended to learn from foreign experience and use an employment contract plus the “Physician's Law” to control all medical practices. Allowing all practicing doctors to register at the provincial level health administration can practice more. The health administrative department is mainly responsible for providing policy guarantees and supervision to ensure information and medical safety.

There are many departments involved in the practice of doctors, especially if there are obstacles in the system. If we do not try to change from the basic medical system, the current multi-practice exploration will be difficult to achieve the desired goals.

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Beware of Reduced Service Efficiency Huang Yan encourages senior doctors to use their spare time to go out part-time, which is one of the directions of medical reform. Beijing officially launched a doctor's multi-practice system, which triggered a "grab of experts." Beijing Coal General Hospital has taken the lead in signing cooperation letter of intent with 160 experts from 23 major hospitals in the city.

Part-time doctors, from "default" to "publicly recognized", is a major advancement in medical reform, but it is necessary to ensure that it has more advantages and less harm, avoid new problems, and constantly modify and improve.

The senior doctor's part-time job seems to be beneficial to doctors, patients, and hospitals, but it is not without disadvantages. The author's concern is that if the management of the doctor's part-time job is improper or lacks management, the problem of low service efficiency will occur again, which will make the medical quality unstable, the medical cost not fall, and ultimately be detrimental to both the patient and the hospital.

Low service efficiency is a common fatal problem in public hospitals. It can cause a three-lost outcome: First, it is difficult and expensive for patients to see a doctor. Second, it causes idleness and waste of hospital resources and increases in costs. Third, doctors pay more than they do. The return, that is, the doctor's workload, but the benefit is not high.

The specific performance of inefficient services is varied. For example, hospitals do not open clinics or operate during the weekends and holidays; patients lack guidance in seeking medical treatment, leading to blind worship of experts by experts; 80% of diseases treated by experts are minor diseases; and patient service procedures are tedious. The lack of continuity of services and the concept of "patients' full management"; doctors' overall treatment arrangements for inpatients are not economical and efficient, and lack of rehabilitation centers (hospitals). The average length of hospital stay is high; the degree of electronicization is not high.

Medical reform attaches great importance to how to improve the efficiency of medical services. At present, the government and hospitals have taken various measures to increase efficiency, such as the implementation of electronic medical services in many hospitals; there are no holiday clinics in major hospitals in Beijing; Peking Union Medical College Hospital encourages doctors to go out of the clinic with a full registration fee to return doctors; The three hospitals implement night surgery; some hospitals implement doctor-level referral systems, night clinics, day surgery, and one-stop full-service; the government invests in the establishment of community health institutions and rehabilitation centers (hospitals) to regulate the patient's medical treatment. Behavior, shortening the average length of stay for patients; medical reform also encourages hospitals to use clinical pathways. Unfortunately, many measures to increase efficiency are still tentative and have not yet been universalized and institutionalized.

The doctor's part-time job means that the doctor's mobility increases, which is likely to affect the continuity of the doctor's service to the patient in the hospital and the hospital, and ultimately lead to a decline in service efficiency. This is not good for both the patient and the hospital. The expert is not a divine doctor. His diagnosis and treatment of the disease is not one step. He needs to manage the patient in order to ensure that his entire diagnosis and treatment is more economical and efficient. Only by allowing part-time doctors to establish the concept of "full-patient management" can we improve service efficiency, and doctors can achieve a win-win situation when they work part-time.

Therefore, the author believes that hospitals should pay attention to the management of part-time doctors, including: 1. Strictly regulate the work duties that part-time doctors must perform in this hospital. It is required that part-time doctors or experts must personally participate in the key links of some medical services in this hospital and cannot be replaced by juniors or interns, such as communicating with patients and their families before and after surgery. 2. It is necessary to guard against the occurrence of doctors who are interested in going out for part-time work and are interested in delaying the diagnosis and treatment of patients in this hospital. 3. Part-time doctors are required to establish the concept of "full-patient management" and take the initiative to fulfill their overall management responsibilities. 4. It is suggested that the doctor should be a part-time job and can choose to work part-time with the nearest medical institution in this hospital, so as to improve the efficiency of patient management.

In short, low service efficiency is a common problem in hospitals. It is a system problem as well as a management problem. With the increase in doctors' part-time work and the increase in the mobility of doctors, if hospitals do not attach importance to efficiency management and do not establish the concept of “full-patient management”, the service efficiency of hospitals and patients will be compromised again, resulting in declining medical quality and medical costs. rise. We must guard against the possible side effects of the new medical reform measures and ensure that the new measures look beautiful and actually more beautiful.

(The author is former Chung Ying College Hospital Management Researcher)

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What we can do for the grassroots professor Zhang Yuqi, professor of neurosurgery at Beijing Tiantan Hospital, optimizes the surgical conditions of secondary hospitals. From the current domestic neurosurgery field, we must admit that the development is not balanced, and there are huge differences in the level of diagnosis and treatment. This difference needs the government to be limited. High-quality, high-efficiency medical resources (mainly high-level practicing physicians, ie, human resources represented by well-known experts) perform reasonable redistribution. This kind of redistribution is conducive to improving the unbalanced status of talents in the tertiary and secondary medical units and narrowing the gap.

To ensure the level of diagnosis and treatment of neurosurgical diseases, especially the quality of surgery, there are many influencing factors, such as the surgical technique of the surgeon, perioperative treatment, basic facility conditions, the configuration and level of medical staff, and so on. Among them, neurosurgical surgical instruments mainly include surgical microscopes, microsurgical instruments, head frames, and automatic brain retraction systems. These hardware conditions are currently available in most secondary hospitals in China, but the degree of proficiency in use is also Not enough, especially when doctors use microscopes to spread widely compared to large hospitals. Signing experts can provide assistance or suggestions for improvement, and further strengthen the hardware conditions of hospitals through multi-practice practice and promote the mastery of high-precision equipments by grass-roots doctors.

Improve the quality of surgery in secondary hospitals According to past experience, experts usually give targeted lectures to doctors and nurses of supported departments while performing surgery. There are many kinds of brain tumors. Each patient has different tumor growth sites and different nature. The surgical methods or means used are also not the same. Postoperative patients have different clinical symptoms. All these need to be told to them, what to pay attention to before and during and after surgery in terms of medical care and care, especially in some difficult cases are more special. Through many years of consultation or surgery, these medical staff have a more comprehensive understanding and grasp of surgical patients, so as to continuously improve the medical level of medical staff in supported departments.

I hope that the ultimate goal is to enable the supported departments to independently complete the diagnosis and treatment of more complex brain diseases through multi-practice medical practice in other medical units. This requires a medical team in a department to have a higher medical standard. Hospitals established with independent neurosurgery have basic neurosurgical care and can meet the requirements for the diagnosis and treatment of common diseases and multiple diseases in neurosurgery, but they need to be improved in the diagnosis and treatment of difficult diseases. The hospital adopts open measures such as going abroad (such as study, academic meeting, and visit), inviting experts (inviting experts to attend consultations, and giving lectures), and hiring experts with higher surgical skills to perform surgery in hospitals with the above basic conditions. The high level of diagnosis and treatment technology and academic thoughts are provided to the supported hospitals. This has benefits for hospitals, doctors, patients, society, and so on.

In the past decade or so, I have often visited other hospitals across the country for consultation or surgery. I think this is also an important duty of our doctors. Physicians now practicing more points of practice are stipulated on a legal level and have more legal validity than previous regulations. It can completely change the kind of disorder that doctors used to go out of the cave and protect the doctor's safety. (This reporter Yu Yuanshen finishing)

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The best thing for Li Yi to do for free practitioners is not to ask what changes have taken place in the policy and to study their own business. I personally wanted to be such a doctor, but my fate was a joke with me.

Due to some factors, I had to leave the original unit, the Third People's Hospital of Yunnan Province, in February 2009, and went to the St. John's Private Hospital. At that time, there were 21 members who came out with me. For the survival of this group of people, I could not do business but I tried to explore the path. Now our team is officially registered as a team of doctors. The commonly known Li Yi team has the scientific name of "Renqing Team." We now pay our own wages, purchase social insurance, and so on.

When we signed a multi-practice employment agreement with the Third People's Hospital of Yunnan Province, we enjoyed the same treatment in terms of responsibilities, rights, and benefits as those in the provincial hospital. We feel very warm. At present, our team and St. John's Hospital are also contracted to practice. I was appointed as the director of the Center for Cardiovascular Diseases by the Provincial Third Hospital and was responsible for the center's medical, teaching, scientific research, personnel training, and administrative management.

The state promotes diversified medical treatment. Doctors practice more as one of the modes we experience. We also feel the benefits of this system. But it is like the existence of a variety of plants in the forest to balance and vitality. Like exuberant, other models also need to exist, and thriving is not necessarily good. Looking back at the initial trials in the past two years, I have some experiences with doctors practicing in more fields:

First of all, more practice is beneficial to the hospital. Judging from the two points that we are currently practicing, the three hospitals in the province are well-integrated and continue to develop. St. John's Hospital has achieved good results and stable performance. Previously, the entire hospital of St. John's Hospital had a monthly income of less than 1 million yuan. Now, the monthly income of a department of cardiology alone exceeds 3 million yuan, and the average monthly operation volume is about 150 units. In 2009, the provincial hospital's cardiology business doubled its revenue in one year. The number of surgeries increased from about 40 units per month to more than 100 units, and the number of patients increased significantly.

Second, more practice has indeed eased the problem of patient care. An old patient who lives in the southern urban area said: "My family is closer to St. John's. It's much easier to come to Saint John to see you."

Third, practicing more is good for doctors. For our own purposes, we interacted with each other and with the doctors of the Third Provincial Hospital and St. John's Hospital to learn from each other and promote the exchange of people and technology. The level of diagnosis and treatment has been continuously improved. In medical activities, teamwork is very important. The hospitals we practice are composed of surgeons and assistants who work in harmony with them and are familiar with various inspection and treatment facilities. This multi-point practice reflects the superiority of teamwork. Compared with the traditional temporary consultation, it avoids the disadvantages of the lack of tacit understanding and unfamiliar equipment, and the doctor's work is no longer a guest identity. This is very important. Doctors work with the owner's mind, doctors and patients will be more harmonious, and medical quality will be more assured.

Of course, at present, doctors practicing more points are still at the exploratory stage and there are certain risks. How to manage multi-practice doctors is very important, as if there are no traffic lights, traffic will be chaotic. We very much hope that the management physicians will practice “traffic light” more points, formulate corresponding systems, and deal with possible controversial issues, making this work more standardized, scientific, and institutionalized.

(The author is a contract doctor from the Third People's Hospital of Yunnan Province and the Department of Cardiology, St. John's Hospital, Yunnan Province)

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When the two parties sign the contract, they will negotiate the price of the U.S. professor of internal medicine at Ohio University. Wu Yunpeng’s medical system and practice environment in North America are very different from those in China. Doctors' qualifications are related to the quality of training and subsequent clinical practice. Multi-practice practice is related to the medical market and doctor's contract. There is no fixed model. The legal system in North America supports and regulates the implementation of physician contracts.

First of all, I will introduce the quality management of doctors practicing in North America.

A doctor must carry out clinical practice, must have the clinical license of the state, the qualifications of drug regulatory agencies and medical liability insurance. The clinical license is updated every two years and is reviewed by the state's medical management agency. The drug qualification certificate is updated every three years. The medical liability insurance is issued once a year. The relevant medical insurance company is responsible for the review. All of the above are indispensable. Each organization has its own certification program, which is very complicated and will not be described here.

In addition, the federal health insurance and various medical insurance also require qualification. In order to ensure the quality of medical treatment, doctors are required to have relevant specialist certificates or qualifications. This requires that doctors must go through related specialized training. This kind of training is very harsh and elimination is often the case.

The medical distribution in North America is also uneven, but it is regulated by the market, which has resulted in more practice. More practice can ease the lack of medical treatment, and secondly, it can increase doctors' career opportunities and income. Doctors are freelancers. If they are individuals, they are still practicing “single-point” practice regardless of whether they have opened several clinics or acquired the right to practice medicine in several hospitals. What I would like to talk about here is similar to the practice of multi-point practice in China.

In North America, most doctors are independent of the hospital and the relationships are generally maintained by employment contracts. The contract guarantees that the interests of both parties will not be infringed. Besides the responsibility, obligation, service, and reasons for dismissal, it is necessary for both parties to negotiate a bargaining price. That is, in order to protect their medical resources and markets, the hospital generally asks for non-competition clauses. (NON-COMPETENT). This provision will require that a doctor be hired to operate within a certain area (from ten miles to the nearest county). There are generally restrictions on the work of signing non-competition clauses in medical institutions, such as the nature of work, working hours, etc., and charitable work is not restricted. These can be bargained for. As for medical liability insurance, it is generally regulated in the contract. In most cases, the hospital is responsible for the coverage of the insurance coverage. Medical liability insurance, which is covered by doctors, is relatively free of coverage. The doctor's contract is very complicated and generally requires a special lawyer to check it.

In North America, the hospital's certification of doctors (CREDENTIALING) is complex and serious, including medical education qualifications, medical background checks (errors, corrections and expulsions, liability insurance is rejected, letters of recommendation, etc.). For example, when the hospital found that the recommendation letter had bad opinions, it would contact the recommender directly. Medical institutions have disciplinary regulations and can disqualify doctors from appointment. For example, some doctors were disqualified from smoking in the operating room, and some doctors were expelled from the medical system for violation of the Ethical Code (ETHICS). These doctors are in big trouble when they re-certify. In addition, hospitals will provide various conditions to retain outstanding doctors.

Doctors are relatively independent and basically independent of the administration of the hospital. Most professional management committees of the hospital are composed of doctors. In addition, the hospital will ask doctors for feedback every year to improve the quality of service. In North America, hospital management is also very professional and professional.

- Background links -

In August 2008, Yunnan Province launched a multi-practice pilot in Kunming City. As of the end of October 2010, Kunming City handled more than 1,098 physician practitioners, and the administrative staff accounted for 4.77% of the registered physicians in Kunming.



The Kunming Health Bureau stipulates that a physician with a deputy chief physician or higher title and intends to apply for more practice doctors can apply directly to the municipal health administrative department for multi-practice physician registration without requiring the consent of the practicing medical institution. However, physicians who take the title of physician or above must first obtain the consent of the practicing medical institution before they can apply for more practice registration.