“2013年，我将离开体制执业，为中国善良优秀的医生们寻找一条新路。”2012年12月9日，同济大学附属东方医院血管外科主任、著名血管外科专家张强医生在微博上公布的这条消息在医疗界激起强烈反响。

"In 2013,,I will leave the system practice,For good good doctors in China looking for a new road."December 9, 2012,Eastern hospital affiliated to tongji university director of vascular surgery/Famous vascular surgery expert doctor zhang qiang in micro bo the news published in medical aroused strong repercussions.

　　张强医生跳出体制外执业被不少业内人士解读为中国医生的自由执业探路。医生自由执业和传统的体制内执业有何区别？它能否成为中国医改的一个方向？如何推动医生的自由执业？为此本报记者采访了相关专家。

Doctor zhang qiang jumped out of the system of practice was a lot of the personage inside course of interpretation for the freedom of the Chinese doctors practising units.The doctor free practice and the traditional system in practice is the difference?It can become a direction of the reform in China?How to promote the practice of freedom?Therefore our reporter interviewed the relevant experts.

　现状：“看病难”呼唤医生自由执业 Current situation:"To see a doctor difficult"Call the doctor free practice

　　医生自由执业，就是获得执业资格的医生可以自主选择执业方式和执业机构，有选择“个体行医、合伙行医或者受聘于医院行医”的自由。而不像现在，公立医院是事业单位，公立医院的医生是“单位人”，要想自由流动，必须经过医院同意。世界上大部分国家都实行医生自由执业，医生依靠自己的医疗技术和服务质量，获得相应的报酬，没有红包、回扣，没有过度医疗、大药方……

The doctor free practice,Is to obtain the qualification for the doctor can choose practicing way and institutions,Have a choice"The individual practice/Partnership practice or employed by the hospital doctor"The freedom of the.But not like now,Public hospital is institution,Public hospital doctor is"Unit one",If you want to free flow,Must pass the hospital agree.Most countries in the world is a doctor free practice,Doctors rely on our own medical technology and service quality,Get the corresponding reward,Not a red envelope/rebate,Without excessive medical treatment/The prescription...

　　中国早期医生也可以自由执业，只是到了后来才被收编到公立医院。张强医生认为，收编到公立医院的做法在特定时期起了相当大的作用。但是随着老百姓医疗需求多元化，它便很难满足社会的医疗需求，一个突出表现就是公立医院的公益性越来越模糊，造成了有人感觉“看病贵”，有人花钱却买不到需要的医疗服务。而且受制于公立医院的体制之困，医生的医疗价值得不到充分体现，医患纠纷也越来越多。而一旦医生自由执业，参与市场竞争，不但可以帮助医生提高医术竞争力，还可以让医生更加注重自己的品牌服务，而不敢乱开大药方、搞过度医疗。因而，恢复医生自由执业应该是医改的一个大方向。

Early Chinese doctors are free to practice,Just arrived later was incorporated into the public hospital.Doctors think zhang qiang,Incorporated into the practice of public hospital played a considerable role in certain period.But as people medical needs diversification,It is difficult to meet the medical needs of the society,A prominent manifestation is the social benefits of public hospitals is becoming more and more fuzzy,Caused some feeling"High cost",Some money but can't buy the needs of medical services.And is subject to public hospital system of sleepy,The doctor's medical value is not fully embody,Doctor-patient dispute will be more and more.Once the free practice,Participate in market competition,Not only can help improve the doctor medical skill,Also can let the doctor pay more attention to their own brand service,To mess up prescription/Make excessive medical treatment.thus,Restore the doctor free practice should be a focus of medical reform.

　　中国社科院经济所公共政策研究中心主任朱恒鹏认为，医生和律师一样，都是靠专业知识和经验积累吃饭，只要通过政府或者一些社会组织比如行业协会的统一考试，获得了执业资格，就应该成为自由执业人。实行自由执业，形成规范透明的医生服务价格决定机制，让医生获得与劳动相等的报酬，也就避免了收红包的现象。医改需要解决的一个问题就是医疗服务定价机制，只要医疗服务价格涨了，医生开方量必然会减少，也可以挤压药品的回扣和返利空间。同时，医生服务价值得到了体现，就会释放更大的医疗生产力，从而增加医疗供给，解决“看病难”问题。某种意义上说，衡量医改是否成功的一个重要标志就是看医生是否实现了自由执业。

Chinese academy of social sciences economy ZhuHengPeng, director of the center for public policy research,Doctors and lawyers,Depend on professional knowledge and experience to dinner,As long as through the government or social organizations such as the unified exam of trade associations,Get the qualification,You should become a free professional person.The freedom to practice,Form a standardized and transparent doctor service price decision mechanism,Let the doctor to get labor and equal pay,Will avoid the phenomenon of the red envelope.Medical need to solve a problem is medical service pricing mechanism,As long as the medical service price,The doctor's quantity will reduce,Also can squeeze drug kickbacks and rebate space.At the same time,The doctor service value obtained,Will release more medical productivity,Thus increasing medical supplies,To solve the"To see a doctor difficult"The problem.Some sense,An important symbol to measure the success of the reform is to see the doctor whether the free practice.

　困境：体制“瓶颈”限制医生自由执业 trouble:system"bottleneck"Restrict the freedom of the practice

　　2009年，卫生部专门发文要求试点医生多点执业。这打破了《执业医师法》“一个医生只能在一个注册医疗机构行医”的规定，被认为是破除公立医院垄断、调动医生积极性、医疗服务合理定价的关键举措。

In 2009,,Ministry of special articles required pilot doctor more practice.It broke[Practice YiShiFa]"A doctor can only be registered in a medical practice of medical institutions"The provisions of the,Public hospital is considered to be breaking monopoly/To motivate the doctor/Key medical service and reasonable price.

　　朱恒鹏认为，多点执业只能算一个过渡性说法，最终的制度安排应该是自由执业。就目前而言，医生要实现多点执业，一般要通过医生个人申请、所在医院同意、卫生局登记注册3个步骤。在公立医院，需要院长审批的多点执业几乎等于形同虚设。因为医疗人才与技术是医院最大的竞争力，没有哪个院长愿意把优质资源无偿送到其他医院。况且，医生在科研、教学、学术职称评定上都由医院说了算，申请多点执业相当于公开宣布自己“有二心”，用身份保障换执业自由，多数医生不敢冒这个险。

ZhuHengPeng think,More practice is only a transitional,The final system arrangement should be free to practice.For the moment,The doctor in order to realize more practice,General will through the personal application/In the hospital agree/Health bureau registered three steps.In a public hospital,Need the approval of the dean more practice almost equal to be evaded.Because of medical personnel and technology is one of the largest the competitiveness of the hospital,No director is willing to deliver high quality resources for free to other hospitals.besides,The doctor in scientific research/teaching/Academic evaluation on all the hospital have the final say,Apply for more practice to publicly"There are double",With identity freedom in practice,Most doctors can't take the risk.

　　广东省卫生厅副厅长廖新波认为多点执业是医改提出的一个方向，但在试点中遇到了体制“瓶颈”，具体表现在：其一，多点执业只限于“具有中级以上医学专业技术职务任职资格”，并且还要“第一执业地点同意其多点执业”，限制过多；其二，公立医院的体制一定程度上阻碍多点执业。公立医院的事业单位编制根本不允许其医生到其他地方“走穴”，而且让医生抛弃编制，也很不现实。因而，在廖新波看来，“张强现象”是对现有医疗制度的一种挑战，是“凤凰涅槃”，但能否重生还有待观察。

Deputy head of guangdong provincial health bureau liao new wave that more practice is one of the medical reform put forward direction,But in the pilot in the system"bottleneck",The specific performance in:one,More practice is limited to"With intermediate above qualifications medical professional and technical posts",And will be"The first practicing sites agree with it more",Limit too much;The second,Public hospital system to some extent hindered more practice.Public hospital of the institution of don't allow the doctor to other place"Money imparting knowledge to students",And let the doctor away,Is not realistic.thus,It seems to liao new wave,"Zhang qiang phenomenon"Is a challenge in the current medical system,is"Phoenix nirvana",But can regenerate remains to be seen.

　　出路：赋予医生自由执业合法性 A way out:The doctor free practice legitimacy

　　张强在微博中称，“离开体制，意味着放弃事业单位的编制，经受传统偏见带来的市场和行业挑战。但这一切都会值得，因为于国、于民、于医，都是一条必经之路。于我，则是重新探索自我之旅。”张强的个人探索能否为中国医生的自由执业探路？现在看来还有很长一段路要走。

Zhang qiang said in micro bo,"Leave the system,Means giving up the establishment of the institution,Through the market and industry challenge of traditional prejudice.But all this will be worth it,Because in the country/To the people/In the medical,Is a necessary way.In my,Is a new exploration ego trip."Zhang qiang's personal exploration can practice units for the freedom of the Chinese doctor?Now it still has a long way to go.

　　医改虽然提出了多点执业的探索，以缓解“看病难”，然而3年过去，多点执业在各地普遍遇冷，不少省份申请人数不足百人，在一些城市甚至出现“零申请”。

Although medical reform put forward more practice exploration,In order to alleviate"To see a doctor difficult",However, in the past 3 years,More practice in throughout the freeze,Many provinces apply for fewer than one hundred people,In some cities even appear"Zero application".

　　针对如何推进多点执业，如何由多点执业向自由执业过渡等问题，廖新波认为，首先应修订现在的《执业医师法》，赋予医生自由执业的合法性。没有法律的支持，现在的多点执业就不可持续，更谈不上自由执业。其次要厘清医改中政府和市场的界限，让市场的归市场，政府的归政府。政府所要做的就是提供基本公共医疗服务，其他的如自由执业可以交给市场。

Aiming at how to promote more practice,Problems such as how to by more practice transition to free practice,Liao new wave of thought,First of all should be revised now[Practice YiShiFa],Give the doctor practicing the legality of freedom.Without the support of the law,Now the more practice is unsustainable,Much less free practice.Secondly to clarify the reform of government and the boundaries of the market,Let the market to market,The government to the government.The government need to do is to provide basic public health services,Other such as free practice can to market.

　　朱恒鹏认为，公立医院的改制是实现自由执业的前提，像眼下80%的医院是公立医院，90%的医生在公立医院，很难实现自由执业。具体做法可借鉴国企改革的经验，老人老办法，新人新办法，即继续给离退休的医师按照现行制度发放退休金，现在在岗的医生保留国有事业编制身份及相应待遇，从此取消公立医院的国有事业编制，新人全部采用合同制，和医院签订劳动契约关系。

ZhuHengPeng think,The practice of public hospital reform is the realization of freedom,As is now 80% of the public hospital,90% of the doctors in public hospitals,It is difficult to realize free practice.Specific practices can be use for reference the experience of the reform of state-owned enterprises,The old man old way,New new way,That continue to retired physician pensioned according to the current system,Now on-the-job doctor keep state-owned business of identity and the corresponding treatment,Public hospital since then cancel the state-owned business,New all adopt the contract,And hospital sign labor contract relationship.

　　然而，张强医生则认为，医院的性质不需要改变，但在人事管理上必须进行改革，最起码在管理理念上要允许医生多点执业。同时让医生参与到医改中，争取自己的话事权。

However,,The doctor think zhang qiang,The nature of the hospital don't need to change,But must reform in personnel management,At the very least to allow doctors to practice more on the management concept.At the same time let the doctor take part in the reform,Try to yourself's voice.

　观察眼 Observe the eyes

　　自由执业是把双刃剑 Free practice is double-edged sword

　　医改要改的也是当前这种“以药养医”的不合理定价体系，既然想让医生的价值通过医疗服务价格来体现，而不是通过开大药方、过度治疗、收红包来体现，那么就当允许医生自由执业。

Reform is to correct the current this kind"Medicine to support medical"The unreasonable pricing system,If want to let the doctor through the value of medical service prices to reflect,Not by prescription/Excessive treatment/The red envelopes to reflect,So as to allow doctors to free practice.

　　这倒让人想起了上个世纪的“赤脚医生”，他们倒更像自由执业者。不过当时社会还处于“熟人社会”，医患关系十分和谐。可是眼下不断发生的医患冲突早已让医患关系处于失信状态。因而，在这样的现实环境下来讨论医生的自由执业，似乎有点过于理想化。一个最简单不过的问题，医生成为自由执业者，那么就必须要有严格的监管配套来保障患者的利益，可是现下的监管机构显然很难令人放心。

It reminds people of the last century"Barefoot doctors",They more like free practice.But society is still in"Acquaintances society",The doctor-patient relationship is very harmonious.But for now keep the doctor-patient conflicts have let the doctor-patient relationship is in a state faithless.thus,In such a realistic environment down to discuss the doctor's free practice,Seems a little too idealistic.One of the most simple question,The doctor a free practice,So there must be strict supervision necessary to protect the interests of patients,But now the regulators is obviously hard to trust.

　　即便是在美国等发达国家，医生成为自由职业者也是有前提的：首先，有严格的住院医师培养制度和规范化的护士培训，大小医院的管理水平差异也不大，所以医生自由行医风险不大；其次，他们的民营医院发育很充分，与公立医院形成强有力的竞争关系；此外，他们的社会保障体系相当完善，医生不用担心失业风险……

Even in the United States and other developed countries,Doctor be freelancers are prerequisite:In the first place,Have strict and standardized resident training system of nurse training,Size of the hospital management level difference is not large also,So the doctor free medical risk is not big;The second,Their civilian battalion hospital development is very full,And public hospital form the strong competitive relationship;In addition,Their social security system is perfect,Doctors don't have to worry about unemployment risk...

　　因而，自由执业也是双刃剑，配套制度不完善、市场竞争不充分只会加剧医患冲突。但医生自由执业应是大方向所在，让医生“自由”的核心是要解除公立医院对医生劳动力的垄断，通过市场使医生的价值得到体现。这要强化公立医院的公益性；二是给民营医院平等的机会和更大的空间，在职称评审、资格认定上与公立医院一视同仁；三是实行“严进宽出”的医师执业考核关，从源头上杜绝“江湖郎中”的勾当。(子在渊 记者李佳莉 李龙)

thus,Free practice is also a double-edged sword,Supporting system is not perfect/Market competition is not sufficient only exacerbate the doctor-patient conflicts.But doctors free practice should be in focus,Let the doctor"free"The core of public hospital is to remove the monopoly of the labor force to the doctor,Through the market to the value of the doctor.This should strengthen the social benefits of public hospital;Two is equal opportunities to civilian battalion hospital and larger space,In the title appraisal/Qualification and public hospital alike;Three is a"Strict in wide out"Physician practice examination,From the source to eliminate"You sucker"The business of.(In journal reporter LiJiaLi having. His)