【作者】 黄星；

【导师】 韦波；

【作者基本信息】 广西医科大学 ， 流行病与卫生统计学， 2014， 博士

【摘要】 背景基层卫生人才是目前急需的医学人才，我国从2010年开始实施“农村订单定向免费培训项目”，主要培养在基层从事全科医疗的订单式全科医学人才；近几年，各高等医学院校相继加入到订单式全科医学人才的培养队伍中，均在进行人才培养的探索。依据评价学、教育学等理论与方法进行教育质量评价研究，判断订单式全科医学人才培养的模式、课程设置等教学环节是否适应人才培养需求，人才培养质量是否满足基层医疗卫生服务的要求，己成为医学教育急需开展的重要课题。CIPP评价模式是目前应用较广泛的教育评价模式，包括背景评价、投入评价、过程评价、结果评价四个步骤。目的1.根据CIPP评价模型，通过对广西基层卫生服务机构全科医生的人力资源需求及现状的调查，了解开展订单式全科医学教育的背景。2.通过对广西三所高等医学院校订单式全科医学人才培养现状的研究，了解订单式全科医学人才培养的基本情况、培养模式、师资力量、课程设置及教学改革等，了解开展订单式全科医学教育的投入及过程。3.采用SERVQUAL（Service quality）模型，构建学生使用的“高等教育服务质量满意度量表”，并评价量表的信度和效度；通过订单式全科医学生对高等医学院教育服务质量满意度评价及基层就业意向的调查、与五年制临床医学生教学效果的比较，了解订单式全科医学教育的培养效果。4.针对全科医学人才培养进行SWOT战略分析并提出相应对策建议。方法1.采用文献分析法搜集、查阅、分析和整理订单式医学教育和国内外全科医学教育开展的相关政策文件和发展现状，进行高等教育评价、教育服务质量满意度评价国内外研究现状和趋势的综述。2.采用文献分析法、专家咨询法设计针对各类对象的调查问卷；采用问卷调查法，选取基层卫生服务机构全科医生、高等医学院校管理人员、教师和学生作为调查对象，就订单式全科医学教育的背景、投入、过程和结果进行调查分析。3.采用小组访谈法，使用自编的访谈提纲对高等医学院校教学管理人员进行访谈，了解其对于订单式全科医学教育开展的建议。4.采用数理统计法，用均数、标准差、百分比、构成比及t检验、卡方检验、方差分析和Binary Logistic非线性回归模型对所搜集到的数据资料信息进行整理、分析、计算、解释。5.采用SWOT分析法，分别针对高等医学院校和政府部门就全科医学人才培养提出有针对性的对策建议。结果1.数量上，广西基层卫生服务机构（含社区卫生服务机构和乡镇卫生院）目前仅有全科医生1907人，要达到每万名居民有2～3名全科医生的目标，仍需全科医生9061～14545人，数量缺口大；质量上，广西基层卫生服务机构全科医生学历以本、专科为主，中级及以下职称占95%以上，工作内容以基本医疗工作为主，公共卫生服务工作处于次要位置，实际操作技能落后，学习能力欠佳。2.在订单式全科医学人才培养的投入上，广西三所医学院校对开展订单式全科医学教育非常重视，在招生规模、人才培养目标的制定、教学经费、教学设施、机构设置、实践教学基地和师资队伍建设等各方面，均投入了大量的人力、物力和财力。现有理论教学师资的水平基本能满足学校理论课的教学要求，但合格的临床师资和社区师资比较欠缺。3.在订单式全科医学人才培养的过程上，广西三所医学院校均针对基层医生的岗位需求，单独制定订单式全科医学生的人才培养方案，在课程设置和课程改革上，进行了不同的探索和尝试。4.“教育服务质量满意度量表”的Cronbach’α系数为0.97，重测Pearson’s系数为0.96，结构效度提取公因子累计贡献率为63.74%，该量表信度、效度较好。广西三所医学院校“教育服务质量满意度量表”各项目的平均分位于2.82～4.15之间，广西医科大学全量表平均得分较高，其次是右江民族医学院，最后是桂林医学院，学生满意度由高到低的维度为：可靠性、保证性、有效性、有形性、移情性、反应性。不同年级学生量表平均分有差别，而性别、民族、生源地、是否独生子女、党员和学生干部等个人基本信息对学生量表平均分无影响（p＞0.05）。5.订单式全科医学生年龄以24岁以下为主，75%来自于农村，近90%为非独生子女，近90%的家庭人均年收入低于万元，父母多为农民及中学或以下文化。学生选择此专业的原因多是家人建议和无学习费用压力，73.0%的学生表示愿意到基层就业，广西医科大学学生下基层的意愿较高，桂林医学院、右江民族医学院两所院校仅有50%～60%。多因素分析显示，学校教育服务质量满意度较高、入学时间不久、汉族、父亲文化程度较低、对国家政策了解、入学原因为为家乡基层人民服务、选择到基层就业的原因非受入学前合同限制的学生基层就业意向较高（p＜0.05）。订单式全科医学生在基层就业的思想道德与职业素质上优于五年制临床医学生（p＜0.05），而在医学理论知识掌握方面与五年制临床医学生无明显差别（p＞0.05），订单式全科医学教育在校教学效果良好。6.围绕订单定向医学生的培养现况、培养模式、师资及基地建设等问题进行的访谈，来自广西三所医学院校的12名教学管理人员针对学校教育体系及政府支持方面提出了10余条建议，为订单式全科医学教育的开展提供参考。订单式全科医学生对高等医学院校开展订单定向医学教育提出的建议共有285条，主要集中在课程设置、培养方案、教学管理、考研指导、师资队伍建设、实践教学、思想教育、政策宣传、招生、国家政策等方面。结论1.在人才培养的背景需求方面，基层医生的数量和质量都远远不能满足需求。通过订单式培养的模式，能解决基层医学人才需求量大与学生基层就业率低的矛盾，是缓解目前基层医学人才供应紧张的有效途径。2.在人才培养的投入和实施过程方面，广西三所医学院校从办学指导思想到机构设置、教学条件、实践基地、师资队伍等各方面均投入了大量的人力、物力和财力。在教学过程中，构建满足基层全科医疗服务需求和医生未来职业发展的课程体系，还配备了专职辅导员对学生进行专业思想教育，学校对于订单定向医学教育的投入和实施过程得到了学生的肯定。3.在订单式全科医学教育的效果方面，订单式全科医学教育培养效果良好，通过5年的在校教育及规范的全科医学方向的毕业后教育，为基层医疗机构培养出合格的全科医生，可以在一定程度上缓解基层医学人才紧缺的现状，并且通过引进高学历、有系统医学教育背景的医学人才，最终实现改善基层医学人才质量结构的目的。4.通过SWOT战略分析，结合全科医学人才需求与现状、全科医学学科发展趋势，从高等医学院校和政府部门两个层面提出加强全科医学教育的具体对策与建议：高等医学院校应构建全科医学教育体系、转变教育理念等；政府部门应加强过渡期全科医学人才培养、完善体制机制保障等。更多还原

【Abstract】 BackgroundMedical professionals are urgently needed in grassroots of China. Thecountry has been implementing “Rural-oriented Tuition-waived MedicalStudents Training Program” since2010, which aims to cultivate general medicalprofessionals who embark on general medicine at grass-level. Many medicalcolleges have joined order-based general medical education and are exploringgeneral medical professionals training. Based on evaluation, education, othertheories and methods to assess educational quality, and determine whether thetraining mode and the curriculum are adapted to the need of order-basedprofessionals cultivation, and whether professionals cultivation quality meetsthe needs of primary health care services have become essential issues ofmedical education that should be urgently solved. CIPP model is extensivelyused in evaluation, and four steps include context, input, process and product evaluation (short for CIPP).Objective1. To investigate the situation of human resources and the demand ofgrassroots general practitioners for health services in Guangxi based on theCIPP evaluation model; to understand the current work situation of grassrootsgeneral practitioners there and make context evaluation of order-based medicaleducation.2. By studying the current situation of order-based general medicalprofessionals’ cultivation of three medical colleges in Guangxi, we can know thebasic information, training mode, teaching forces, curriculum arrangement andteaching reform of order-based general medical professionals’ cultivation, andcarry out input and process assessment of order-based general medicaleducation.3. Adopt SERVQUAL (service quality) model to construct “Educationalservice quality satisfaction scale” used by students, and evaluate the reliabilityand validity of the Scale. Investigate the order-based students’ satisfactiontoward education service quality, grassroots employment intentions, andteaching effects comparing with5-years medical students to assess the productof order-based general medical education.4. Use SWOT (strengths, weakness, opportunities, threats) strategy toanalyze general medical education in medical colleges and propose suggestions.Methods1. Use document analysis to collect, consult, analyze and sort out therelevant policy documents of order-based general medical education and generalmedical education and the current study situation of all medical colleges, andthen conduct higher education evaluation and education service quality satisfaction evaluation, and make a conclusion about the current study situationand trend at home and abroad.2. Use document analysis and expert consultation to design questionnairesfor all types of objects. Use questionnaires, and select general practitioners,medical colleges, teachers and students from grassroots health services asinterviewees to analyze the background, input, process, and products oforder-based general medical education.3. Use group interviews to interview medical colleges’ administers, and toknow their recommendations about order-based general medical educationdevelopment.4. Use mathematical statistics, means, standard deviation, percentage,proportion, T-test, chi-square test, analysis of variance and Binary Logisticnonlinear regression models to sort out, analyze, calculate explain on thecollected data.5. Use SWOT strategic analysis to put forward proposals for medicalcolleges’ general medical education.Results1. In quantity, general practitioners in Guangxi grassroots health serviceshave a big gap; in quality, general practitioners in Guangxi grassroots healthservices got relatively lower education and job title, and their job contents aremainly basic medical work, and public health service is placed in a secondaryposition; their practical skills are backward, and learning abilities are poor.2. On the input of order-based general medical professional cultivation,three medical colleges in Guangxi attach much importance to order-basedgeneral medical education. They invest a lot of manpower, materials andfinancial resources in enrollment scale, institution establishment, goal-setting of professional cultivation, practice teaching base and teaching force construction,etc. The existing theories teaching forces can meet the basic needs of schools’teaching theory courses, but qualified clinical teachers and community teachersare not enough.3. In the process of order-based general medical professional cultivation, allthe three medical colleges in Guangxi formulate separate schemes fororder-based general medical students in accordance with job requirements forgrassroots doctors, and they also explored and tried with different methods incurriculum arrangement and curriculum reform.4.“Educational service quality satisfaction scale” includes six dimensions,fourteen primary indexes and thirty-two secondary indexes. The Cronbach alphacoefficient is0.97and the cranial Pearson’s coefficient is0.96. The commonfactors of the structure validity could explain63.74%of the total variance. Thusthe scale has good reliability and validity. The average score of all projects inthe "educational service quality satisfaction scale" is between2.82to4.15, andthe average full-scale score of Guangxi Medical University is higher thanYoujiang Medical University for Nationalities. In addition, Guilin MedicalUniversity got the lowest score among the three medical universities. Thedimension of students’ satisfaction degree from the highest to the lowest isbelow: reliability, assurance, effectiveness, tangibility，empathy，and reactivity.There exist differences in the average score of students in different grades.However, the personal information, such as gender, nationality, birthplace,whether they are only-child, party members or student cadres or not and so on,has no significant difference to the students’ average score（p＞0.05）.5. Most of the order-based general medical students are under24years oldand75%of them are from rural areas; close to90%of them are none-only child; near90%of the families’ annual per capita income is less than ten thousand;most of their parents are farmers and primary school or middle school graduates.Families’ suggestion and the pressure of no tuition are the main reasons whythese students choose this major. Seventy-three percent of the students arewilling to take up occupations in grass-roots units. Students in Guangxi MedicalUniversity have higher willingness than the students in Youjiang MedicalUniversity for Nationalities and Guilin Medical University. There are only50%to60%of students who are willing to take up occupations in grass-roots units inthe Youjiang Medical University for Nationalities and Guilin MedicalUniversity. Some students have high satisfaction degree of school educationservice quality and short years of schooling, and they are from the Hannationality and understand national policy. Some students’ fathers have lowculture level. Some students’ reason for enrolling is that they want to service thepeople in their hometowns. Moreover, some students are not forced to work inthe grassroots by the contract before enrollment. All of these students are morewilling to take up occupations in grass-roots（p＜0.05）. Teaching effects ofmoral and professional qualities and medical theoretical knowledge betweenorder-based general medical students and5-years medical students show that theorder-based general medical education also has good effect.6. After the interview which centered on the issues such as the currentcultivation circumstance, training mode, teachers, base construction and so on,total twelve teaching management personnels from three medical universities ofGuangxi offered more than10proposals for school education system andgovernment support, and also give good references for the development of theorder-based general medical education. Order-based general medical studentsput forward285proposals for the medical colleges to develop the order-based general medical education. These proposals are mostly focused on curriculaprovision, training scheme, teaching administration, guides for postgraduateexams, construction of teachers, practical teaching, ideological education,policy propaganda, enrolment of students, and the national policies-making andso on.Conclusions1. The quantity and quality of medical professionals in grassroots are farshort of demand. Order-based general medical education can solve thecontradiction between high demands for grassroots medical professionals andthe low employment rate of students at grass-level by order-based training mode,which is an effective way to ease the current tight supply of grassroots medicalprofessionals.2. The results of the “educational service quality satisfaction scale” meansthat the devotion and the implement process of the order-based general medicaleducation gained the approval of students.3. The order-based general medical education has good teaching effect.Students have willing to work in the grassroots medical organization aftergraduation, which can ease the situation of the shortage of grassroots medicalpersonnel. The goal of improving the quality structure of grassroots medicalpersonnel can be achieved by introducing medical personnel who are welleducated and have the background of systemic medical education.4. From the medical colleges’ level and the governmental departments’level, we should put forward the specific measure and suggestion forstrengthening the education of general practice through SWOT strategic analysisand through combining the demand and situation of general practice medicalpersonnel. The measures and suggestion include the establishment of general practice educational system, change of the educational ideas, strengthening ofgeneral practice talents training in the transitional period, completing the systemguarantee and so on.更多还原