[If the civil servants are assigned and supervised, medical reform will never be improved]

On June 9, ********** presided over the Executive Meeting of the State Council and determined measures to deepen the reform of the public hospital salary system, including: reasonably increasing the total amount of hospital salary; appropriate tilts for public hospitals that have heavy public welfare tasks and undertake scientific research and teaching tasks; the internal distribution model can be tilted towards key positions and medical personnel with outstanding performance.

"The vast majority of medical staff protect the lives and health of the people and have made outstanding contributions to the fight against the epidemic. Many medical staff's daily workload is beyond imagination and respectable." Premier *** said at the meeting.

The salary distribution can be tilted towards several types of doctors.

Low-age doctors, non-staff salary needs to be increased

According to the "China Government Website" of the State Council, the decision of the meeting on that day involved two aspects: "the distribution of overall salary for public hospitals in various places" and "the distribution of salary for medical personnel within public hospitals":

1. Improve the mechanism to determine the salary level of public hospitals.

Relevant departments should dynamically adjust the salary level of public hospitals on the basis of ensuring that the overall burden of medical treatment does not increase.

Public hospitals such as heavy public welfare tasks and undertake scientific research and teaching tasks should be appropriately given priority.

All localities should comprehensively consider factors such as workload, service quality and other factors at different levels and natures to reasonably increase the total salary.

2. Implement internal distribution autonomy in public hospitals.

Take into account the total amount of salary and related factors in a coordinated manner and continue to improve the job performance salary system.

It is also possible to independently determine other more effective internal distribution models based on actual conditions, and tilt towards key positions and medical staff who are urgently needed by the masses, and promote better solutions to the problem of difficult medical treatment in serious illnesses and other aspects.

Appropriately increase the salary level of low-age doctors and comprehensively consider the salary and benefits of internal and external personnel.

This news has aroused heated discussions among many doctor station app users:

It is reported that as early as 2009, the Central Committee of the Communist Party of China and the State Council issued the "Opinions on Deepening the Reform of the Medical and Health System", requiring the implementation of a comprehensive performance appraisal and job performance wage system.

In 2016, ******* proposed "two permits", that is, allowing medical and health institutions to "break through the current salary regulation level of public institutions", allowing medical service income to deduct costs and withdraw various funds according to regulations to "mainly use them for personnel rewards". This speech was regarded as a direction for reforming the salary system of public hospitals.

However, from the recent documents such as the "Opinions on Promoting the High-Quality Development of Public Hospitals" issued by the State Council, it can be seen that although some regions and hospitals have actively explored the reform of the wage system and made certain progress in recent years, they have not yet met the requirements of establishing a personnel compensation system that adapts to the characteristics of the industry.

On June 4, the "Opinions on Promoting the High-Quality Development of Public Hospitals" requires the implementation of the "two permits" proposed five years ago.

"The situation requires that the salary system must be changed, otherwise it may lead to instability in the medical staff of public hospitals in the future." Yesterday, Xu Yucai, deputy director of the Health and Family Planning Bureau of Shanyang County, Shaanxi Province, wrote an article titled "Prime Minister: Determining the Reform of the Payment System of Public Hospitals for the "Medical Think Tank" and said.

Expert: Remuneration reform is imminent,

Details are still missing

Xu Yucai pointed out that for a long time, the income and contribution of medical staff in my country have not been equal. From 2016 to 2017, the Chinese Medical Association conducted a questionnaire survey on 146,200 doctors nationwide. The "White Paper on Practice of Chinese Physicians" formed shows that doctors at all levels work about 50 hours a week; doctors at tertiary hospitals have an average annual income of 86,000, while doctors at second-level and first-level levels have less than 70,000; doctors with senior professional titles have an average income of 108,000.

"The characteristics of the medical industry are: long training cycle, high occupational risks, high technical difficulties, heavy responsibility, and reasonable salary should be obtained." On June 7, Xu Shuqiang, director of the System Reform Department of the National Health Commission, publicly stated.

"Generally speaking, compared with manufacturing employees, the income of medical staff is not too low. However, in terms of occupational requirements and risks, the income of medical staff is significantly lower." In response to Prime Minister ***'s latest speech, Beijing Youth Daily commented that the poor salary distribution system is the main reason for the abnormal behavior of medical staff, the reduction of work enthusiasm, and the loss of talents in public hospitals. In the long run, the burden on patients will be increased, and medical disputes will continue to arise.

Prime Minister *** also said: "We must use this salary system reform to accelerate the reform of relevant supporting systems and promote better solutions to the problem of difficult medical treatment in serious illnesses and other aspects."

"Prime Minister: Determining to Deepen the Reform of the Payroll System in Public Hospitals!" shows that gray income such as kickbacks, red envelopes, commissions, etc. once made up for the lack of sunny income of medical staff, but to some extent, it also "blocked" the pace of salary system reform. However, with the vigorous implementation of measures such as volume-based procurement in recent years, the complete cancellation of drug bonuses, cracking down on commercial bribery, fraud in insurance fraud and reform of medical insurance payment systems, doctors' gray income has decreased.

In addition, during the COVID-19 pandemic, Chinese people have witnessed the hard work of medical staff. "A strong signal from the highest level: the new medical reform has come to this day, and the reform of the salary system has reached a time to speed up the pace." The above article said.

However, in addition to the doctor's "gray income" block, the process of salary reform in public hospitals is also affected by various factors. For example, the total amount of hospital performance wages depends on the hospital's own income generation, and the hospital will pay performance wages to each department based on economic income assessment as the standard; the total amount of performance wages is actually paid to all employees in the staff, resulting in the squeeze of the allocation quota and it is difficult to fully mobilize the enthusiasm of medical staff.

"For some low-income hospitals with insufficient fiscal allocation and poor income status, reforming the salary system cannot solve the difficulties they face. Medical staff can raise their salary expectations through salary reform, but the hospital may not be able to pay or cannot bear the necessary costs of the reform." Xu Yucai admitted in the article.

In this regard, on the premise that there is little room for increasing fiscal investment, Beijing Youth Daily recommends the orderly relaxation of the medical market, encourage private investors to invest in the establishment of private hospitals and participate in the mixed ownership reform of public hospitals, and at the same time shift the focus of work to industry supervision.

"There is still a lack of specific implementation details at the operational level." Regarding salary reform, Xu Yucai wrote an article saying that due to the differences in regional economic development level and government funding levels, the gap between different public hospitals, different positions, different seniority, different departments, and between internal and external staff members, etc., how to establish a reasonable proportion of the gaps.

【Pregnancy and puerperal vte(1/2)】

Venous thromboembolism (VTE) is a collective name for deep venous thrombosis (DVT) and pulmonary embolism (PE). Deep venous thrombosis refers to the disordered venous return caused by abnormal blood coagulation in the deep vein. It often occurs in the lower limbs, and a few are found in the mesenteric vein, upper limb vein, jugular vein or intracranial venous system; if thrombosis is blocked in the pulmonary artery, it will lead to pulmonary embolism. Deep vein thrombosis in pregnant women, the risk of pulmonary embolism and the mortality rate caused by venous thromboembolism are significantly higher than that in normal people. In recent years, with people's lifestyle

Changes and adjustments to my country's fertility policy, the number of obesity and pregnancy complications or comorbidities in elderly pregnant women is increasing, and the incidence of venous thromboembolism during pregnancy and puerperal period has increased significantly, seriously threatening the life safety of pregnant women. Screening for high-risk factors of venous thromboembolism and early prevention can effectively reduce its incidence. However, medical institutions at different regions of my country and at all levels have uneven prevention strategies and cognitive levels of venous thromboembolism. Therefore, it is particularly necessary to formulate prevention and treatment standards for venous thromboembolism during pregnancy and puerperal periods that are suitable for my country's national conditions.

Based on the reference to the vascular surgery group of the Chinese Medical Association's Surgery Branch, the Royal Academy of Obstetrics and Gynecology Association of Obstetrics and Gynecology (RCOG), the Canadian Obstetrics and Gynecologists Association (SOGC), the Queensland Health Organization, Australia (QLD), the American Obstetrics and Gynecologists Association (ACOG), the American Chest Physicians Association (AACCP), and the Obstetrics and Gynecologists (ACCP), and other related guidelines for the prevention and treatment of venous thromboembolic diseases, combined with high-level clinical research evidence and actual situation in my country, obstetrics experts across the country have discussed and prepared my country's first "Expert Consensus on Prevention and Diagnosis of Venous Thromboembolic Diseases during Pregnancy and Puerperal Periods", aiming to guide and standardize the screening, diagnosis, treatment and prevention of venous thromboembolic diseases during pregnancy and Puerperal Periods.

1. Overview of venous thromboembolism during pregnancy and puerperal period

(I) Epidemiological status of venous thromboembolic disease

Compared with non-pregnant women, the incidence of venous thromboembolic during pregnancy and puerperal period increased by 4 to 5 times. Foreign data show that the overall incidence of venous thromboembolic during pregnancy and puerperal period is 0.6/1    000~1.8/1    000, of which the first week after delivery is the period with the highest risk of disease. In venous thromboembolic during pregnancy and puerperal period, deep venous thromboembolic accounts for 75% to 80%, with an incidence of 1.0/1     000~1.3/1     000, and the incidence of pulmonary embolism is 0.2/1      000~0.4/1     000. Data from Mary Hospital, Hong Kong, China shows that the incidence of deep venous thromboembolic is 0.4/1      000, and the incidence of pulmonary embolism is 0.07/1       000.

(II) Pathogenesis and related risk factors of venous thromboembolic disease during pregnancy and puerperal period

Question 1: What is the pathogenesis of venous thromboembolic disease during pregnancy and puerperal periods?

【Recommended and consensus】

1?1     The risk of venous thromboembolic disease is increased due to special physiological and anatomical changes during pregnancy and puerperal periods. (Evidence level: Expert consensus)

The occurrence and development of venous thromboembolism during pregnancy and puerperal period is closely related to the special physiological and anatomical changes during this period. These changes will increase the risk of thromboembolism, including estrogen, elevated progesterone levels, changes in the coagulation system (coagulation factor 7, coagulation factor 8, coagulation factor 10 and fibrinogen, decreased anticoagulant factor protein s, protein c, etc.), platelet function activation, blood stasis, blood vessel damage, uterine enlargement and compression of the inferior vena cava and pelvic vena cava, and decreased mobility during pregnancy and postpartum. The above changes make the body have the "three elements" of the formation of venous thromboembolism (hypercoagulation state, slow blood flow rate, and damaged blood vessel walls), thereby increasing the risk of the occurrence and development of thromboembolism.

Question 2: What are the risk factors for venous thromboembolic disease during pregnancy and puerperal periods?

【Recommended and consensus】

2?1   The occurrence of venous thromboembolic disease during pregnancy and puerperal period is closely related to the amount and degree of combined-related risk factors. The more risk factors, the higher the risk, and the greater the risk of venous thromboembolic disease. (Evidence level: Expert consensus)

The occurrence of venous thromboembolic disease is related to many risk factors. If the physiological changes during pregnancy and puerperal period are combined with relevant risk factors, the risk of venous thromboembolic disease will be significantly increased. According to the characteristics of different risk factors, it is summarized into four categories:

(1) History of venous thromboembolism or venous thromboembolism: including past history of venous thromboembolism, venous thromboembolism that still exists after treatment, etc.

(2) There are comorbidities related to the occurrence of venous thromboembolic disease: active autoimmune or inflammatory diseases, nephrotic syndrome, heart failure, type 1 diabetic nephropathy, sickle cell disease, malignant tumors, etc.;

(3) Temporary risk factors: surgical surgery during pregnancy, hyperemesis gravida, ovarian hyperstimulation syndrome, etc.;

(4) Obstetrics and other risk factors: family history of venous thromboembolic disease, advanced age, birth rate, obesity, paraplegia or prolonged braking, systemic infection, multiple pregnancy, preeclampsia, cesarean section, prolonged labor, stillbirth, severe postpartum bleeding or massive blood transfusion, etc.

2. Diagnosis of venous thromboembolic disease during pregnancy and puerperal period

Question 3: How to identify venous thromboembolic diseases during pregnancy and puerperal periods early?

【Recommended and consensus】

3?1    There are lower limb pain and swelling, you need to be highly vigilant about the occurrence of deep venous thrombosis. (Evidence level: Expert consensus)

3?2    If you experience symptoms such as neck swelling, indifference, headache and vomiting, you should be wary of embolism in the jugular vein and intracranial vein system. (Evidence level: Expert consensus)

3?3    If you experience symptoms such as dyspnea, chest pain, cyanosis, etc., you should be wary of the occurrence of pulmonary embolism. (Evidence level: Expert consensus)

About 90% of deep vein thrombosis during pregnancy and puerperal periods occur in the left lower limbs, and are mainly iliac vein and femoral vein. Most patients with deep vein thrombosis have no symptoms in the early stage or lack specificity. The earliest and most common clinical manifestations are pain, swelling, accompanied or without the increase in skin temperature and redness. In addition to swelling of the lower limbs, iliac vein thrombosis may be accompanied or without pain in the waist, abdomen, buttocks or back. The circumference of the affected side of the calf is different from the opposite side>

2     cm                                                                                                                                                                                                                                                         
Chapter completed!