北京市郊区全科医生接诊儿童现况及其影响因素的质性研究

Status and Associated Factors of Clinical Encounters of General Practitioners with Pediatric Patients in a Suburban District of Beijing:a Qualitative Study

背景社区全科医生作为儿童基本医疗服务的主要提供者,其接诊能力直接反映基层儿科诊疗水平。我国儿童医疗服务的供给与需求存在较大区域差异,且基层儿科医疗服务能力不足,郊区全科医生接诊儿童现况及相关影响因素是值得关注的问题。目的了解北京市郊区全科医生接诊儿童现况,分析制约郊区全科医生接诊儿童的主要因素,以期为儿童疾病分级诊疗的开展提供参考。方法于2021年6月,采用目的抽样法,选取参与“北京市密云区医共体建设暨全科医生综合服务能力提升项目”的全科医生作为研究对象,对其进行半结构化焦点小组访谈,了解郊区全科医生接诊儿童现况及相关影响因素。应用NVivo 12软件对访谈内容进行编码、归类,采用主题框架分析法对资料进行整理和分析,并提炼访谈主题。结果共纳入19例访谈对象。其中男5例;年龄24~51岁,平均年龄(33.2±7.6)岁;18例学历为本科;9例职称为主治医师;1例参加过“5+3”全科医师规范化培训,8例参加过“3+2”助理全科医师规范化培训;8例参加过全科医生转岗培训;从事全科医疗工作的年限为1~18年,平均年限(6.3±4.8)年。基于访谈资料,共提炼出4个主题:郊区全科医生接诊儿童的数量和病种均较少,且接诊的儿童以3岁以上为主;郊区全科医生接诊儿童的自信心普遍不高;制约郊区全科医生接诊儿童的因素(家长对全科医生的信任度低、全科医生诊疗能力不足、儿童疾病诊疗风险高、护士执行能力不足、社区卫生服务中心缺乏儿童用药和实验室检查设备、尚无明确的儿童转诊制度);促进郊区全科医生接诊儿童的方法(儿科专家社区出诊、增加针对儿童的药品及实验室检查设备配备)。结论北京市郊区全科医生接诊儿童仍存在诸多问题和挑战,基层接诊儿童现况堪忧。加强对郊区全科医生的儿童疾病诊治能力培养,加强全科与儿科间的协同合作,对健全儿童疾病分级诊疗体系具有重要意义。

Background As the main providers of essential pediatric services,the capabilities of community general practitioners(GPs)in managing pediatric patients may directly reflects the overall status of pediatric care services in primary care settings.In China,there are great regional differences in the supply and demand of pediatric services,and the capabilities of primary care settings are unsatisfactory in providing pediatric services.The current encounters and influencing factors of GPs with pediatric patients in suburban districts are worthy of attention.Objective To understand the status and associated factors of clinical encounters of GPs with pediatric patients in a suburban district of Beijing,providing a reference for the development of tiered diagnosis and treatment of pediatric diseases.Methods In June 2021,purposive sampling was used to recruit GPs who participated in a training named"Beijing Miyun District Medical Consortium Construction&General Practitioners'Comprehensive Capability Improvement Project"to attend a semi-structured group interview for understanding the status of clinical encounters of GPs with pediatric patients and related influencing factors.The interview results were recorded,and transcribed,then coded using NVivo 12,and analyzed using thematic analysis.Results Nineteen GPs(5 men and 14 women)in the age range of 24-51 years〔average age of(33.2±7.6)years〕,attended the interview,18 of whom had a bachelor degree;9 had a title of attending physician;1 had participated in the standardized general practice residency program;8 had participated in the"3+2"assistant general practitioners training program;8 had participated in the standardized training before making a career change into general practice.The average years of them working a GP was 1-18 years〔(6.3±4.8)years on average〕.Four themes emerged from the analysis:(1)Both the numbers of pediatric patients and illnesses encountered by suburban GPs were less than those encountered by their urban counterparts,and pediatric patients encountered by suburban GPs aged greater than or equal to 3 years.(2)Suburban GPs generally had a low level of self-confidence in treating pediatric patients.(3)The major factors negatively affected suburban GPs encountering pediatric patients include the pediatric patient's parents with a lower level of trust in their GP,inadequate capabilities of GPs in managing pediatric patients,high risk of managing pediatric patients,underperformance of nurses,inadequate available pediatric medicines and equipments for laboratory tests in the community,and lack of a clear referral system.(4)The major facilitators for suburban GPs to encounter pediatric patients include managing pediatric patients in the community by pediatricians,and increasing pediatric medicines and equipments for laboratory tests.Conclusion The encounters of suburban GPs with pediatric patients in primary care were unsatisfactory due to many problems and challenges.To improve the situation,it is suggested to improve the capabilities of suburban GPs in managing pediatric patients by trainings,the collaboration between GPs and pediatricians,and the tiered system for the diagnosis and treatment of pediatric diseases.