乡村医生职业嵌入的内卷化困境与治理路径

作为深度嵌入国家的红色赤医之延续,乡村医生在改革开放后40年间呈现脱嵌样态;21世纪以来,村医职业逐渐在制度、结构与认知层面回嵌于国家。引入内卷化概念梳理其嵌入过程发现,在强国家-弱法团的单向度主导与村医自主悬搁之耦合下,村医职业嵌入正在遭遇内卷化危机:以技术理性为表征,精细化、繁复化与形式化的制度干预与规制直接作用于村医职业内容与边界,职业去专业化风险由此滋生;乡-村两级医疗卫生组织间关系的变动与收入结构的调整使得职业管辖权不断弱化,村医职业的法团自主性进一步消弭;职业身份的错置、模糊化与科层化伴随着对药物使用的规制,村医在认知嵌入过程中开始遭遇临床自主性丧失危机,由此带来了基层卫生消解医疗的非预期性后果。在市场与社会之外整合职业社群的力量乃是实现村医职业的发展型嵌入的必行之计。

The Occupational Embedding of Rural Physicians:The Dilemma of Involution and Governance Path

As the continuation of the barefoot doctors deeply embedded in the country,rural physicians were once de-embedded in the country.Since the beginning of the new century,the rural physicians profession has gradually been embedded in the country at the system,structure and cognitive level.Introducing the concept of involution and combing the process of re-embedding,we can find that under the coupling of the lock-in endogenous and autonomous suspension of the village medicine profession,the profession is encountering Involved crisis:Refined,complicated and formalized system intervention and regulation directly affect the professional content and boundaries of rural physicians,and the risk of professional de-specialization will breed;Changes in the relationship between township-rural physicians and health organizations and changes in the income structure of rural physicians have continuously weakened professional jurisdiction,and the corporate autonomy of the profession has been further eliminated;The misplacement,ambiguity,and bureaucratization of professional identities are accompanied by the regulation of drug use.Rural physicians begin to encounter a crisis of loss of clinical autonomy in the process of cognitive embedding,which has brought about unintended consequences of primary health care to eliminate medical care.How to realize the developmental embedding of the rural physicians profession?It is necessary to integrate the power of the professional community outside the market and society.