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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 modelBiopsycho-social medical model and its views of healthImpact of biopsychosocial medical model on medicine and society,一、医学模式概念及其演变,Concept and Evolution of medical m
2、odel,1.社会医学:模式Model in Social Medicine,Initially,concept of mathematical logicHighly simplified theoretical thinking of the fundamental nature of medical practiceAbstract 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 Model,Natural
3、istic 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,function,structur
4、e 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 medicineGuiding principleTheory as well as methodology towards Health and disease,3.医学模式的演变过程Evolution of Medical Model：,神灵主义的医学模式(Spirit
5、ualism 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 modelHow to look at health and disease?,Life and health is bestowed by the GodDisease is caused by
6、supernatural powersOnce 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 spirit away,The natives of New Britain ascribe sickne
7、ss,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 ground with wild howls till morning,believing that this drives
8、 away the devils;they rush through the village with burning torches.,Spiritualism medical model,Treatment:Pray to God and spirits for bless,forgiveness&their protectionResort to natural plants or minerals for treatment,most is of emetic and cathartic Banish the spirits and ghosts that cause plague,治
9、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 into two broad categories that were both opposite and complementary.The two p
10、oles 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 otherMetal:cutting,hard,conductingWood:growing,flexible,rooted,strong Water:wet,cool,descendingFire:dry,hot,asc
11、ending,movingEarth: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 simultaneously exist in everyone and everything and within each other.Yin represents the cold,slow,or passive pri
12、nciple,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 causes of diseases,The Causes of disharmony External Causes:Six external evilswind,cold,heatdamp,dryness,fire,失调的原因 外因：六淫风寒
13、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 environmental causes.A towns weather,drinking water,and site along the paths of favorable winds can help a physician ascertain the general health of
14、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 observations 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 he
15、aling process of rest,a good diet,fresh air and cleanliness.The first physician believes that thoughts,ideas,and feelings come from the brain and 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 E
16、xternal 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 Hippocrates on Modern Medicine,Hippocrates reject that:diseases have a supernatural cause.first person to perceive a relationship between cause and effect in a mechanist
17、ic wayProviding 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 phl
18、egm,blood,black bile and yellow bile.Health-mutual balanceDisease-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、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 o
19、ne 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,Significance 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 th
20、e origin of the*integration*of Western medicine with early Greek naturalistic science.The pathogenesis 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 primari
21、ly mystical approach to disease which was characterized by the worship of gods,the fending off 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
22、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 bodyIll health is 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 IdeasGrowing acceptance of a developing scien
23、tific model.Development of research,observation,technologyNew ways of thinking about 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
24、alive,than any man-made automata,meaning a machine that moves itself.,从运动的角度：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
25、dualistic.These two things or parts interact,and each affects the other.Medicine should pay more attention to body than its mind.,代表人物及其主要观点：,Descartes:Animal is MachineLamterry:Human is Machine,a machine start up itselfRegard life activities as machine movementProtect health is just as the same way
26、 of protecting a machineDiseases:in a state when machine breakdown 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 cha
27、nges by precise technique,explain symptom,interfere 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
28、 results between its cause and effects,二元论：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 theoryPhysiologyAnatomyHistologyEmbryologyPathologyImmunologyGeneticsMolecular Biology,细
29、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分子生物学,Achievements under bio-medical model外科学三大难题被攻破,Three big issues in surgeryacheInfectionBlood 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 air1870s Pasteur demonstrates that germs are the cause ra
30、ther than the product of disease1880s Robert Koch-Doctrine of Specific etiologyeach 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 Patho
31、logyDisease 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)：biome
32、dical 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,恩格尔指出:生物医学
33、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 holismInteraction of body and mindMulti-causalitySocially connected individual Preventative-health maintenance,整体医学观 身体和精神的整合 多因多果-病因链 个人与社会的联系
34、 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 PatternIncreasingly diversified demand for health Socialization of medicine Interior amalgamation and exterior intersection of medicine disciplines,疾病谱转变健康
35、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 mind from body.It is a re
36、duced,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 medical model,It includes the patient
37、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2-1 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（En
38、vironment 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：Biopsychosocial 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
39、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 dimension）。,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
40、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 di
41、sease）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 medical model,临床医学 预防医学医学教育可持续发展医学目的,Clinical medicinePreventive medicine
42、Medical educationSustainable developmentGoal 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 MakerHealth EducatorCommunity LeaderService Manager,2.生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 challen
43、ges 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 unaffordableThe confusion exists in clinical practiceThe fairness of society is 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
44、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 economyShould be equity and fairnessShould respect the choice and dignity of 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,
