Abstract: To optimize the allocation of medical resources，local governments have successively explored the implementation of the family doctor system in practice in recent years.Although the family doctor system has achieved certain success in some cities，such as Beijing，Shanghai，Chengdu and so on，there are still many problems which restrict the development of family doctor system.Although some literature has pointed out problems in one or several aspects of the family doctor system，it lacks a unified analytical framework.The chronic care model（CCM） has achieved good practical results abroad in which the nurses mainly undertake the tasks of the medical team while the family doctor system in China is based on general practitioners.Both of them are implemented in primary health care institutions，so the effective working mechanism and process design of CCM can provide guidance for improving the family doctor system.Under the framework of the CCM and through theoretical research，this paper finds there are still some shortcomings of the family doctor system in the personnel and process of the service delivery system，the coordination of medical service organizations，the self-management support for patients，the construction of medical information system，decision support，resource allocation，and policy support that impede the advancement of the family doctor system.On the basis of the CCM，this paper proposes some suggestions combined with the practice of the family doctor system in several cities for its future development and improvement，including improving the medical service process with an efficient team，promoting hierarchical diagnosis and treatment system to strengthen the coordination of the medical service organizations，educating patients and paying attention to their self-management，using internet technology to improve the medical information system，increasing policy support to promote the allocation of medical resources.

Key words: Physicians, family；Health care reform；Chronic care model

摘要： 近年来，为优化医疗资源配置，各地陆续在实践中探索实施家庭医生制度。随着实践的发展，各地均取得了一定成效，如北京市、上海市、成都市等地均在不同方面有所创新。但仍然存在一些不足，制约了家庭医生制度的进一步发展。尽管已有部分文献指出了家庭医生制度的某一个或几个方面的问题，但缺乏统一的分析框架。慢性病护理模式（CCM）在国外取得了良好的实践效果，虽其医疗团队中由护士主要承担工作任务，而我国家庭医生制度以全科医生为主体，但二者均在基层医疗卫生机构中实施，CCM高效的工作机制和流程设计，可以为我国完善家庭医生制度的工作模式及流程提供借鉴，以推进家庭医生制度的实施。本文在CCM框架下，通过理论研究发现现今我国家庭医生制度在服务提供系统的人员和流程、医疗卫生服务组织的协同性、患者自我管理支持、医疗信息系统的建设、决策支持、资源分配机制和政策支持等方面存在不足，阻碍了家庭医生制度的推进。在CCM基础上，结合各地已有家庭医生制度的实践，本文对其未来发展和完善提出了完善医疗服务流程，建立高效的团队服务模式；促进分级诊疗，实现卫生医疗服务组织协调联动；加大宣传教育力度，注重患者自我管理；利用互联网技术，加强医疗信息系统建设；加大政策倾斜力度，促进医疗资源合理配置等建议。

关键词: 医师, 家庭；卫生保健改革；慢性病护理模式