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1、第二章 医学模式 Medical model,哈尔滨医科大学 社会医学教研室,内容 Contents,医学模式概念及其演变 生物心理社会医学模式与健康观 生物心理社会医学模式对医学和社会的作用,Definition and evolution of medical model Biopsycho-social medical model and its views of health Impact of biopsychosocial medical model on medicine and society,一、医学模式概念及其演变,Concept and Evolution of medi
2、cal model,1.社会医学: 模式 Model in Social Medicine,Initially, concept of mathematical logic Highly simplified theoretical thinking of the fundamental nature of medical practice Abstract model (or conceptual model),最初是数理逻辑概念，即用系统中的一系列公式来表达形式逻辑理论 人类在与疾病抗争和认识自身生命过程中得出的对医学本质的高度概括 抽象的思想观念和思维方法,2. 医学模式 Medical
3、 Model,Naturalistic and Philosophical view and methodology. In line with the viewpoint and method of materialism and dialectics to observe, analysis and cope with the issues related to the health and diseases. The core of medical model is the viewpoint of medicine, it mainly deals with the attribute
4、, function, structure and the law of medical development,以医学为对象的自然观和方法论，即按照唯物论和辩证法的观点和方法去观察、分析和处理有关人类的健康和疾病问题。 核心是医学观，研究医学的属性、职能、结构和发展规律。,The role of Medical model ?,The soul of social medicine Guiding principle Theory as well as methodology towards Health and disease,3. 医学模式的演变过程 Evolution of Medic
5、al Model：,神灵主义的医学模式 ( Spiritualism medical model) 自然哲学的医学模式 (Nature philosophical medical model) 机械论的医学模式 (Mechanistic medical model) 生物医学模式 (Biomedical model) 生物心理社会医学模式 (Bio-psycho-social medical model)。,a.神灵主义医学模式 Spiritualism medical model How to look at health and disease?,Life and health is be
6、stowed by the God Disease is caused by supernatural powers Once offend the gods, or disfavored by the gods , disease is in the form of the punishment by the gods Possession of evil spirits, demons or monsters etc,生命和健康由神所赐； 疾病是由超自然的力量所引起的； 人触犯神灵时，疾病代表神灵的惩罚； 疾病是妖魔鬼怪附体。,Strategy1: drive the evil spiri
7、t away,The natives of New Britain ascribe sickness, drought, the failure of crops, misfortunes, to the influence of wicked spirits. when many people sicken and die, the inhabitants of a district, armed with branches and clubs, go out by moonlight to the fields, where they beat and stamp on the groun
8、d with wild howls till morning, believing that this drives away the devils; they rush through the village with burning torches.,Spiritualism medical model,Treatment: Pray to God and spirits for bless, forgiveness & their protection Resort to natural plants or minerals for treatment, most is of emeti
9、c and cathartic Banish the spirits and ghosts that cause plague,治疗方法： 乞求神灵的祝福、宽恕和保护 服用具有催吐和导泻作用的植物或矿物质 驱逐瘟神疫鬼,b.自然哲学的医学模式 Naturalistic philosophical medical,THE FIVE elements the physical universe, can be reduced to five elements：wood, fire, earth, metal, and water. Physical universe as divisible in
10、to two broad categories that were both opposite and complementary. The two poles of material phenomena were labeled, “Yin and Yang.“,中国的阴阳 五行学病理学说建立,世界是由什么组成的？ What is the world made of?,Chinese Philosophy Five Elements support and destroy each other，coordinate to each other Metal: cutting, hard, co
11、nducting Wood: growing, flexible, rooted, strong Water: wet, cool, descending Fire: dry, hot, ascending, moving Earth: productive, fertile, potential for growth,中国哲学 五行相生相克、相关协调 金 木 水 火 土,阴和阳 世界观 相生相克,中医对疾病的看法 TCM view of diseases,Illness as an imbalance of two types of energy yin and yang which sim
12、ultaneously exist in everyone and everything and within each other. Yin represents the cold, slow, or passive principle, yang represents the hot, excited, or active principle. Health is a “balanced state“ and that disease is due to an internal imbalance of yin and yang.,中医理论的发病机制,致病的外因： external cau
13、ses of diseases,The Causes of disharmony External Causes : Six external evils wind, cold, heat damp, dryness, fire,失调的原因 外因：六淫 风 寒 暑 湿 燥 火,自然哲学的医学模式西方世界 Naturalistic philosophical medical,Hippocrates： Airs, Waters, and Places , instead of ascribing diseases to divine origin, discusses their environm
14、ental causes. A towns weather, drinking water, and site along the paths of favorable winds can help a physician ascertain the general health of citizens.,希波克拉底：空气、水、地域 探讨环境、天气、水、风向等与健康的关系,Naturalistic philosophical medical model,Hippocrates ,founder of medicine. He based his medical practice on obse
15、rvations and on the study of the human body. He held the belief that illness had a physical and a rational explanation. He believed in the natural healing process of rest, a good diet, fresh air and cleanliness. The first physician believes that thoughts, ideas, and feelings come from the brain and
16、not the heart,希波克拉底西方医学之父,The role of Hippocrates on Modern Medicine,Causes of disease could be internal, relating to faulty aspects of diet and exercise External factors: relating to the forces of climate, winds, water and the seasons.,致病因素内因：饮食和锻炼方面存在问题 外因：环境因素：气候的变化，风、水、季节等,The role of Hippocrate
17、s on Modern Medicine,Hippocrates reject that: diseases have a supernatural cause. first person to perceive a relationship between cause and effect in a mechanistic way Providing the foundation for modern scientific notions of disease causation.,疾病的致病因素的研究推进的医学的发展，否认疾病的产生是超自然力量导致的； 以机械的眼光看待疾病的因果关系 为现
18、代医学的疾病因果理论奠定了基础,西方疾病学说： Western theory of diseases,all matter could be reduced to the basic elements earth, fire, air and water cold, hot, dry and wet; four humour of phlegm, blood, black bile and yellow bile. Health-mutual balance Disease-disorder,自然界万物之源: 水、火、土、气 对应冷、热、干、湿 人体内的：粘液、血液、黄胆汁、黑胆汁相对应 健康
19、、疾病、性格与四体液的数量、比例变化有关 引起体液失衡的原因有先天、环境以及营养失调等,Humoural theory by Hippocrates,Four *bodily* fluids: phlegm, blood, yellow bile and black bile. Disease, in essence, becomes a state in which one of these four bodily fluids (humour) *overpowers* the others.,四体液学说：粘液、血液、黄胆汁、黑胆汁 疾病的本质是：体液之间的失衡状态,Significanc
20、e of Hippocrates,The theory of humour is the first theory which attempts to *integrate* a natural theory of metaphysics with empirical first-hand observations of disease. It essentially marks the origin of the *integration* of Western medicine with early Greek naturalistic science . The pathogenesis
21、 of disease is no longer mystical and inexplicable unnatural causes (demons, gods, etc.),第一次将纯粹的哲学与对疾病的观察结合起来 标志着西医与希腊自然哲学的结合 疾病的发病机理不再是神秘的、无法解释的超自然力量,Significance of Hippocrates,preceded to it: a primarily mystical approach to disease which was characterized by the worship of gods, the fending off
22、of evil demons it successfully separated Western medicine from-a primarily mystical approach to disease . marks the beginning of a rational pathophysiology,希波克拉底之前：疾病是由神秘的超自然力量导致 希波克拉底及其创立的学说将西医与原始的神秘主义分割开来 标志理性病理生理学的真正开端,c.机械论的医学模式 Mechanistic Medical Model,Mechanistic view of the body Ill health i
23、s treated as the mechanical failure of some part of one or more of these interdependent systems and the medical task is to repair the damage.,背景 Background,A Shift in Ideas Growing acceptance of a developing scientific model. Development of research, observation, technology New ways of thinking abou
24、t disease and the body.,思想观念的转变 对不断发展的科学模式的日益认可 研究、观察、技术等科学和技术的不断发展 从新的角度来看待疾病和健康,机械论的医学模式 Mechanistic Medical Model R. Descartes 笛卡尔,From the point of view of movement: Human body is a machine with more parts, but not more alive, than any man-made automata, meaning a machine that moves itself.,从运动的
25、角度： 人体是由许多部分组成的机器,是自己发动自己的机器,笛卡尔的二元理论 Dualistic Interaction of Body and Mind,To Descartes, man was a mind united with a body, the two interacting with each other. Mind and body are two separate things which makes the consideration dualistic. These two things or parts interact, and each affects the o
26、ther. Medicine should pay more attention to body than its mind.,代表人物及其主要观点：,Descartes: Animal is Machine Lamterry: Human is Machine, a machine start up itself Regard life activities as machine movement Protect health is just as the same way of protecting a machine Diseases: in a state when machine b
27、reakdown and body out of order, therefore need to be repaired,笛卡尔：动物是机器 拉美特利；人是机器 是自己发动自己的机器。 将生命活动比作机器的运动 对健康的保护与保护机器的原理一致 疾病：机器出现故障和失灵 医学：对出现故障的部分和零件的修补,d. Biomedical model,Mind/Body dualism: Medicine should focus on measuring cells biochemical changes by precise technique, explain symptom, interf
28、ere changes to recover the health; Reductionism: disintegrates human body to different organ, cells and molecular, the physical and chemical changes at molecular levels can explain the causality of functional changes of body; Disease is regarded as a static results between its cause and effects,二元论：
29、人的身体和精神应有合理的分工，医学应研究如何通过精密的技术测量细胞生物化学的变化，来解释病人的症状与体征，干预这些变化来恢复健康； 还原论：将人体分解为器官、细胞、分子，复杂的生命现象必须用物理的、化学的方法来解释功能改变的因果关系； 疾病是静止的因果结局。,生物医学模式下生命科学的大发展 Boom of Life science,Germ theory Physiology Anatomy Histology Embryology Pathology Immunology Genetics Molecular Biology,细菌学理论 生理学 解剖学 组织学 胚胎学 病理学 免疫学 遗传学
30、 分子生物学,Achievements under bio-medical model 外科学三大难题被攻破,Three big issues in surgery ache Infection Blood loss,外科手术 三大难题： 疼痛 感染 失血,巴斯德：细菌理论 Pasteur : Germ Theory,diseases were transmitted by micro-organisms germs that float in the air 1870s Pasteur demonstrates that germs are the cause rather than the
31、 product of disease 1880s Robert Koch - Doctrine of Specific etiology each disease is always caused by a particular micro organism,巴斯德：疾病是由漂浮在空气中的病源微生物引起的 1870，巴斯德证明了细菌是导致疾病的原因而不是结果 1880科赫：提出特异致病因子的病因理论 认为每一个疾病总是由特异的病源微生物所引起的,魏尔啸：德国病理学家 Rudolf Virchow, German pathologist,Father of Cellular Pathology
32、 Disease can be manifested at microorganism level. All diseases have relation to cell, the source of all kinds of diseases is cells abnormal activities,分子病理学之父 疾病可以在更微观的 分子水平上呈现出来 疾病是由于异常的 细胞造成的,Ecological model of disease,宿主 host,环境 environment,病源体 pathogen,Defects of biomedicine mode,Engel (1980)：
33、 biomedical model neglects the whole because it excludes everything but biological factors. It is preoccupied with the body and disease at the expense of the patient as a person. modern allopathic medicine often fails to address the emotional and spiritual needs of those who suffer from infirmity,恩格
34、尔指出:生物医学不完整,它只考虑了生物因素,而忽视了其他因素； 它的注意力只放在身体和疾病上,而忽视了病人,现代医学的疾病观使其无法满足病人精神和情感需要。,HolisticRather than a new approach, the bio-psycho-social model is actually a return to holism Interaction of body and mind Multi-causality Socially connected individual Preventative - health maintenance,整体医学观 身体和精神的整合 多因
35、多果-病因链 个人与社会的联系 从预防医学到健康维护,二、生物心理社会医学模式 （Biopsychosocial medical model）,（一）生物心理社会医学模式的产生背景 The background of bio-psycho-social medical model,Changing of disease Pattern Increasingly diversified demand for health Socialization of medicine Interior amalgamation and exterior intersection of medicine di
36、sciplines,疾病谱转变 健康需求提高和多样化 医学的社会化 医学学科的内部融合与外部交叉发展,Emerging of Bio-psycho-social medical model,George Engel, alternative to the limited, predominant biomedical model. Bio-medical-model, accounts for disease by its biochemical factors without considering social or psychological dimensions, separates
37、mind from body. It is a reduced, myopic view. Emphasize the hierarchical, independent relationships of biological, individual, family, and community systems.,美国内科医生：恩格尔提出由生物心理社会医学模式来替代生物医学模式 生物医学模式关注导致疾病的生物化学因素而忽视社会、心理的纬度，是一个简化的、近视的观点 强调生物学、个人、家庭、社区和社会系统多层次关系对疾病的影响,Emerging of Bio-psycho-social medi
38、cal model,It includes the patient as well as the illness； Emphasize close attention to be placed on the medical illness and the role the illness plays in the emotional life of the patient, and the interpersonal dynamics of the family.,现代医学模式：不仅关注疾病更关注病人； 医学不仅应关注疾病的本身，还应该关注疾病对人心理和情感的影响，了解病人家庭的关系状况,表2
39、-1 我国城市前五位死因谱的变化趋势,（二）布鲁姆的环境健康医学模式 （Environment health medical model）,（三）拉隆达和德威尔的综合健康医学模式 （Comprehensive health medical model）,环境因素 生活方式及行为因素 生物遗传因素 医疗卫生服务因素,综合内因,卫生服务,遗 传,成熟老化,生物遗传,职 业 危险因素,环境因素,行 为 生活方式,社 会,心 理,自 然,健 康,康 复,治 疗,预 防,生 活 危害因素,消费形式,图2-4 综合健康医学模式,（四）恩格尔： 生物心理社会医学模式 Engel ： Biopsychosoc
40、ial medical model,世界卫生组织提出：“健康是指一种身体心理和社会的完美状态，而不仅仅是没有疾病或虚弱”。 World Health Organization 1948: A state of complete physical, mental and social well being and not merely the absence of disease or infirmity.,（五）生物心理社会医学模式的健康观 （Views of health of modern medical model ）,健康可被理解为生物学、心理学和社会学三维组合（three dimen
41、sion）。,从生物角度 看人的健康 从心理精神角度 观察人的健康， 从社会学角度 衡量人的健康,恩格尔给疾病下了一个定义：疾病可看作是整个生物体或其他系统在生长、发育、功能及调整中的失败或失调。 疾病(disease) 是一种病理状态(生物尺度)， 病患(illness) 是病人说明病理状态的方式(感觉尺度) 患病(sickness) 是病人对病理状态感觉的反应 (行动尺度)。,亚健康状态 （sub-health state ） 指人的机体虽然无明显的疾病，但呈现出活力降低，适应力呈不同程度减退的一种生理状态，是由机体各系统的生理功能和代谢过程低下所导致，是介于健康与疾病之间的一种生理功能降
42、低的状态，亦称“第三状态”或“灰色状态”。,第一状态 健康,第二状态 疾病,第三状态 亚健康,亚临床疾病（subclinical disease） 又称“无症状疾病”( non-symptom disease) 认为疾病是改变了条件的生命现象过程。疾病过程中不仅有机体受损害，发生紊乱的病理表现，而且还有防御、适应、代偿生理性反应。,三、生物心理社会医学模式对 医学和社会的作用 （ Impact of biopsychosocial medical model on medicine and society),1.现代医学模式对医学实践和社会的意义 Significance of modern
43、medical model,临床医学 预防医学 医学教育 可持续发展 医学目的,Clinical medicine Preventive medicine Medical education Sustainable development Goal of medicine,二十一世纪医生的职能： 五星级医生（ five star doctor）,卫生服务的提供者 诊疗方案的制定者 健康教育的指导者 社区卫生的领导者 卫生事务的协调者,Care Provider Decision Maker Health Educator Community Leader Service Manager,2.生
44、物心理社会医学模式的医学目的 （The goals of biopsychosocial medical model）,医学及其目的正面临的挑战： The major challenges facing by medicine and the goals of medicine are ：,经济上不能承受医疗费用过快增长 临床上混乱 社会公平受挫,The rapid increasing of medical costs become unaffordable The confusion exists in clinical practice The fairness of society i
45、s oppressed,走向成熟与完整的医学： Mature and accomplished medicine,应该是有节制的和谨慎的医学 应该是社会供得起的和经济上可支撑的医学 应该是公正和公平的医学 应该是尊重人的选择和尊严,Should be moderate and cautious Should be medicine that could be offered by society and be affordable in economy Should be equity and fairness Should respect the choice and dignity of
46、people,生物心理社会医学模式的医学优先战略： Priority strategies of bio-psycho-social medical model,预防疾病和促进健康； 解除疼痛和痛苦； 治疗疾病和对不治之症的照料； 预防早死和提倡安详地死亡。,To prevent disease and promote health To relieve pain and distress To cure disease and care incurable disease To avoid the premature death and advocate comfortable death,小结 Summary,医学模式的概念 生物心理社会医学模式 生物心理社会医学模式对社会的作用,