Borkan J M
Department of Family Medicine, Faculty of Health Sciences, Ben-Gurion University of the Negev, Beer Sheva, Israel.
J Fam Pract. 1999 Aug;48(8):620-7.
In the last decade managed care has become the major form of health care delivery in the United States. Though some persons believe that managed care is the salvation of family practice, critics claim that it threatens many of the core concepts of primary care. We systematically examined 5 US family practices, to provide a microanalysis of the current situation, particularly from the viewpoint of the care providers.
During 1997 and 1998, case studies were conducted at 5 sites using long interviews, focus groups, and extensive participant-observation of provider-patient and provider-staff interactions. Participants included 54 health care providers, 18 administrators, 45 nurses or nursing assistants, and 30 ancillary staff at the sites.
We found dominant themes of rapid change, disruption, increased demands, interference in clinical decision making, and adaptation. Health care providers have the perception of being in the midst of a revolution with disruptions of key relationships and local knowledge. The clinicians in the study feel a loss of certainty, control, and autonomy.
There appears to be a rampant ideologic competition occurring between business and beneficence for the moral sensibilities of family medicine providers. This is potentially hazardous to feelings of trust in the provider-patient relationship. The focus of much of the warring has been on managed care, though many of today's problems either predated its development or were peripheral to it. More empirical and observational studies are needed to document the fundamental changes taking place in today's health care environment.
在过去十年中，管理式医疗已成为美国医疗服务提供的主要形式。尽管一些人认为管理式医疗是家庭医疗的救星，但批评者称其威胁到了初级医疗的许多核心概念。我们系统地研究了美国的5个家庭医疗实践，以提供对当前状况的微观分析，特别是从医疗服务提供者的角度。
在1997年和1998年期间，在5个地点进行了案例研究，采用了长时间访谈、焦点小组讨论以及对医患和医护人员互动的广泛参与观察。参与者包括5个地点的54名医疗服务提供者、18名管理人员、45名护士或护理助理以及30名辅助人员。
我们发现了快速变化、混乱、需求增加、临床决策受到干扰以及适应等主要主题。医疗服务提供者感觉自己身处一场革命之中，关键关系和本地知识受到了干扰。研究中的临床医生感到失去了确定性、控制权和自主权。
在商业利益和仁爱之间，似乎正在为家庭医学提供者的道德观念展开激烈的意识形态竞争。这可能对医患关系中的信任产生危害。许多争论的焦点一直是管理式医疗，尽管当今的许多问题在其发展之前就已存在或与之无关。需要更多的实证和观察性研究来记录当今医疗环境中正在发生的根本变化。
