神经内科住院医师规范化培训存在的问题与教学 改进

住院医师是医院人才梯队建设的基础,合理地安排培训工作,提高青年医师综合素质,对 培养高层次医学人才至关重要。宣武医院作为北京市首批神经内科住院医师规范化培训基地,近5年已 为社会培育出120名住院医师,取得北京市住院医师规范化培训合格证书。以宣武医院神经内科近5年 培训实践为例,探讨神经内科规范化培训的现状和管理实践,为持续改进培训工作提供参考。     

神经内科住院医师规范化培训探索

住院医师是医生职业生涯中的最初阶段,接受规范化培训非常重要.结合我院神经内科对住院医师培训的实践和经验,我们认为通过职业道德、医患沟通能力,临床技能及团队协作能力等方面的培训,可以提高神经内科住院医师的综合素质,使其适应目前复杂的医疗环境.     

卒中患者病历出院小结现状及其与住院医师规范化培训的相关性研究

目的 调查卒中患者病历出院小结现状，以及住院医师规范化培训与出院小结的关系，梳理目前存在的问题，为下一步制定针对性改善措施提供可靠数据。方法 本研究通过调查一个区域性高级卒中中心连续2个月出院卒中患者病历的出院小结，利用标准病历书写质量（针对书写内容重要元素完整性及质量等7项内容，总分10分）及卒中病历质量评分（包括卒中类型、病因分型、诊疗经过及用药、并发症描述、出院时神经功能评估、预后评估、进一步诊断检查建议、出院用药指导、出院血压及血脂控制目标及治疗随访建议11个项目，每项目计1分，共计11分）对其进行定量评估，了解其现状，总结存在的问题，并比较经过神经专科一阶段培训和未经过培训的住院医师在书写出院小结中暴露的问题差异。结果 共收集卒中患者病历出院小结105份，分别来自6位不同年资的住院医师。标准病历书写质量总体得分为6～10分，平均得分为（9±1）分，＞8分比例为83.8%（88/105），最低分为6分（1份）。主要不达标部分在出院医嘱中关于复诊时间及复查项目方面，比例为50.5%（53/105）。卒中病历质量总体得分为4～10分，平均分为（7±1）分，≥7分比例为76.2%（80/105），不达标比例项最高在血压、血脂控制目标部分，达标比例分别只有6.7%（7/105）和1.0%（1/105）。经过神经专科一阶段培训的高年资住院医师组和未经过培训的低年资住院医师组标准病历书写质量得分均为（9±1）分（P=0.753），各子项得分差异也无统计学意义（P均＞0.05）；两组卒中病历质量评分均为（7±1）分（P=0.335），但在卒中病历质量评分的子项中关于进一步诊疗计划方面，高年资住院医师组书写质量达标比例较低年资住院医师组稍高（95.6% vs. 78.4%，P=0.016）。结论 卒中患者病历出院小结书写质量整体尚可，但具体危险因素控制指标及进一步诊疗随访计划等书写质量还有待于进一步提高。住院医师培养方面，在住院医师专科培训中要突出卒中病历内涵书写的重要性。     

神经内科住院医师规范化培训“单位人”和“行业 内社会人”的临床教学实践

“单位人”和“行业内社会人”是住院医师规范化培训中不容忽视的两类人群，现从首都 医科大学宣武医院神经内科住院医师培训基地的教学实践出发，从临床基本功训练、多模式教学、绩效 考核、建立导师制等方面，探讨对上述两类人群如何进行针对性的教学培训。     

关于中美两国神经内科住院医师培训的一点思考

2011年笔者有幸获得北京市李桓英医学基金资助,到美国Baylor医学院神经内科和全美最大的私立医院Methodist医院的神经内科参观学习。期间主要在神经内科病房和运动障碍门诊学习,因此,有机会了解两院神经内科住院医师的培训情况,并对中美两国住院医师培训进行了一点比较和思考。     

多种教学方法在神经内科住院医师规范化培训中的应用

    针对神经内科住院医师规范化培训过程中存在的神经系统查体不规范,诊断方法认识不足、临床技能培训不够、带教科室管理和培训不得法,提出完善培训制度、改进培训方法等方面的对策,介绍多种教学方法,以便带教老师在有限时间内,高质量完成神经内科规范化培训目标。     

胜任力为导向的神经内科住院医师规范化培训的课程效果评价

目的 评价胜任力为导向的神经内科住院医师培训模式的效果。 方法 选取2016-2020年在北京大学第三医院神经内科完成或正在参加住院医师培训的研究生、 规范化培训的基地学生和住院医师,采取问卷调查或一对一访谈的形式对目前神经内科的系统模式 培训效果进行评价,包括神经内科知识和技能评价以及人文相关内容评价两方面。 结果 共纳入40名医师,培训总体满意度为85%。获益最大的带教方式是“学生为主体”的病例导入 学习（90%）,希望培训的内容包括神经影像学（82.5%）、心电图和胸片等内科基础知识（70%）、肌 电图和脑电图（65%）。最需要提升的疾病种类规培生更多希望掌握常见疾病的诊断和处理,八年制 及硕士研究生则把培训的需求放在罕见疾病的认识和提高。人文素质提升较大的方面包括同情心 和爱伤观念（75%）、职业自豪感（65%）、责任意识（62.5%）。 结论 胜任力为导向的神经内科住院医师培训模式有助于提高专业知识和技能以及人文素质。     

客观结构化临床考试在评价脑血管病住院医师人文沟通能力中的应用

目的 探索客观结构化临床考试（objective structured clinical examination，OSCE）在评价脑血管病 在培住院医师人文沟通能力中的应用，为评价脑血管病在培住院医师人文沟通能力提供依据。 方法 采用OSCE对脑血管病在培住院医师进行专业年度考核，设计6个考试站点（理论、辅助检查、 接诊、病历书写、技能操作、人文沟通），分析在培住院医师各站点的成绩。 结果 共102名在培住院医师参加考核，15名为住院医师，87名为并轨研究生，第一年、第二年、第 三年在培住院医师分别为32名、31名、39名。根据年级不同，第三年在培住院医师的总分[256.3 （95%CI 246.9～261.4）]高于第一年[236.5（95%CI 227.3～244.9）]、第二年住院医师[246.6（95%CI 232.8～256.2）]总分，第二年住院医师考核成绩在接诊患者项目中高于第一年住院医师，以上差异均 有统计学意义。人文沟通成绩得分率低于其余5项考核指标，差异具有统计学意义。人文沟通成绩与 实践、技能操作、病历书写成绩正相关。 结论 OSCE能较好地评价脑血管病住院医师的人文沟通能力，住院医师人文沟通能力不足，需要 加强培训。     

基于问题的学习教学法对提高住院医师在神经眼科疾病中的临床思维能力的作用

神经眼科疾病中相当一部分为跨学科疾病。将基于问题的学习（Problem-Based Learning,PBL）教学法引入到住院医师培训阶段对此类疾病的学习中,带教医师有针对性地选择典型病例,科学地、多方面、多角度地设计问题,指导住院医师对病例分析论证,进行发散性思维训练,使其了解以眼科症状首发的脑血管病这一临床上较少见的眼科-神经内科相关联性疾病,提高其临床思维能力。     

麻省总医院神经内科医师培训启示

美国住院医师制度相对成熟,我国虽然起步较晚,但也在不断完善。本文结合自身经历,分析美国神经内科住院医师培训的特点,旨在取长补短,为我国的医师培训提供参考。     

Diagnostic Difficulties and Treatment Implications

Summary: Differentiation between types of epileptic seizures has been aided in recent years by the introduction of intensive neurodiagnostic techniques and the development of increasingly detailed classification systems. Paradoxically, these developments have not simplified the task of matching the appropriate antiepileptic drug to a particular seizure type. It is reasonable to assume that anticonvulsant drugs will have different effects on different types of seizures, but faulty, circular reasoning can enter the picture if one also assumes that responses of seizures to different drugs signify different seizure types. There are several examples of differential diagnoses that can fall prey to this problem, including the diagnosis between partial seizures with secondary generalization and generalized tonic-clonic seizures, and the diagnosis between complex partial seizures and absence seizures with automatisms, among others. Considerations of etiology in future classification systems can further complicate the problem: should one then choose an anticonvulsant drug on the basis of individual seizure type or on the basis of the type of epilepsy? Ramifications of this issue extend even to the drug approval process. Official sanction is not given for use of a drug for a seizure type not included in the original efficacy studies, even if later scientific evidence shows that seizure type to be related to a type that is included. New trials must be undertaken. These problems arise from how we choose to classify seizures.     

Cognitive Dysfunction Associated with Antiepileptic Drug Therapy

Summary: Epilepsy is frequently associated with cognitive dysfunction. However, the reasons for this correlation are unclear. Possible influential factors include patient age; duration, frequency, etiology, and type of seizures; hereditary factors; psychosocial issues; and antiepileptic drug (AED) therapy. Whereas many of these factors are beyond the physician's control, AED therapy is one element that can be addressed in treatment decisions by recognizing the potential cognitive effects of particular AEDs. For example, phenobarbital impairs memory and concentration; phenytoin affects attention, problem solving ability, and performance of visuomotor tasks. In contrast, carbamazepine may affect concentration, while valproate would appear to have minimal effects on cognition. Moreover, cognitive effects of AEDs are amplified with coadministration of multiple anticonvulsants (polytherapy). A review of studies on the cognitive effects of monotherapy with AEDs, as opposed to those of polytherapy, provides evidence that drug-related cognitive dysfunction can be reversed if patients are switched to a simpler therapeutic regimen. Future research should be directed toward developing reliable measures for assessing and monitoring cognition, and understanding the particular cognitive side effects of each AED. Physicians also need to revise their opinions about which side effects are "tolerable" for epileptic patients.     

Carbamazepine Efficacy in Adults With Partial and Generalized Tonic-Clonic Seizures

Summary: Carbamazepine and phenytoin are drugs of choice in initial monotherapy for adult partial and secondarily generalized tonic-clonic seizures. These designations reflect the results of the Veterans Administration Epilepsy Cooperative Study Group of 1985. An earlier comparative study of carbamazepine and phenytoin by Ramsay and associates found both drugs equally effective in controlling new-onset seizures. Among the advantages of carbamazepine is that it causes relatively few cognitive and dysmorphic side effects. Its disadvantages are its unavailability in parenteral formulation and its metabolic autoinduction. The latter must be compensated for by planned dosage increases to maintain therapeutic plasma steady-state levels during the first 2 or 3 months of treatment. Carbamazepine is judged a drug of choice in the treatment of these secondarily generalized tonic-clonic seizures, and the drug of choice in children, adolescents, and women susceptible to the dysmorphic side effects associated with other anticonvulsant agents.     

Etiologic and Preventive Aspects of Epilepsy in the Child–Bridging the Gap Between Laboratory and Clinic

Summary: Four broad categories of basic phenomena are pertinent to developing ways to prevent epilepsy. These include mechanisms of epileptogenesis, ictal initiation and temporary entrainment by the seizure discharge of normally functioning brain, seizure propagation, and control mechanisms that function both to restrain the cascade of epileptic events culminating in a seizure and to arrest the epileptic event and restore the interictal state. In newborns and children, hypoxia-ischemia is a major factor leading to epileptogenesis, and several schemes are proposed to classify, quantify, and prevent hypoxic-ischemic encephalopathy. Control mechanisms must be better understood in order to develop prophylactic recommendations for epilepsy, and an experimental model of "kindling antagonism" may increase our understanding of these. Programs of prevention of seizures in children will evolve only if basic researchers and clinicians work productively together to develop an adequate understanding of factors important in epileptogenesis and antiepileptogenic control mechanisms.     

Treatment Considerations in Anticonvulsant Monotherapy

Summary: The long-standing practice of polypharmacy in treating epilepsy is giving way to use of monotherapy. Monotherapy can improve seizure control as well as reduce the risk of serious idiosyncratic reactions, dose-related side effects, and complex drug interactions. Monotherapy also offers improved compliance and cost-effectiveness. The basis of monotherapy is accurate diagnosis and assessment of the patient's seizure type(s), followed by selection of a single appropriate anticonvulsant drug. Many patients currently treated with multiple anticonvulsants can be successfully converted to monotherapy with a carefully monitored program in which troublesome and redundant drugs are gradually withdrawn from the therapeutic regimen.     

Predisposing and Causative Factors in Childhood Epilepsy

Summary: We review information from large studies of defined populations, examining the role of known factors and especially of prenatal and perinatal factors in contributing to nonfebrile seizure disorders of early childhood. We depend especially, but not exclusively, on the recently completed analyses from the Collaborative Perinatal Project of the National Institute of Neurological and Communicative Disorders and Stroke, the NCPP. About 4% of children in the NCPP who had at least one non-febrile nonsymptomatic seizure by the age of 7 years had a previous seizure during acute neurologic illness, such as meningitis or during the acute illness after trauma. Many such seizures should potentially be preventable. Of children with seizures, 10% had had a neonatal seizure and 13% had had a febrile seizure. Among the hundreds of prenatal and perinatal factors explored as predictors of childhood seizure disorders, the principal predictors identified were congenital malformations of the fetus, cerebral and noncerebral; family history of certain neurologic disorders; and neonatal seizures. In agreement with the British National Child Development Study, labor and delivery factors in the NCPP appeared to contribute very little to childhood seizure disorders. Maldevelopment, rather than damage at birth to an initially intact nervous system, appeared to be the more common mechanism. Most seizure disorders of early childhood remained unexplained by the large set of prenatal and perinatal characteristics examined.     

Dextromethorphan: Cellular Effects Reducing Neuronal Hyperactivity

Summary: Dextromethorphan is a dextrorotary morphinan without affinity for opioid receptors, commonly used as an antitussive medication. During the past 5 years, interest in the compound and its demethylated derivative, dextrorphan, has been revived because additional neuroprotective and an-tiepileptic properties were found in in vitro studies, animal experiments, and a few clinical cases. Both morphinans are able to inhibit N -methyl-D-aspartate (NMDA) receptor channels and voltage-operated calcium and sodium channels with different potencies. The inhibition of the NMDA receptor is believed to be the predominant mechanism of action responsible for the anticonvulsant and neuroprotective properties of the compounds.     

Anticonvulsant Drugs and Cognitive Function: A Review of the Literature

Summary: Alterations of cognitive function are separate from disturbances of behavior seen in association with epilepsy. The nature of the cognitive disability may to a certain extent depend on the seizure type. Partial seizures, mainly derived from a temporal lobe focus, impair memory tasks, while generalized seizures seem to have more effect on attentional abilities. A number of studies, reviewed in this paper, suggest that anticonvulsant drugs further impair cognitive function. Maximal impairments are seen in patients receiving polytherapy: rationalization of polytherapy improves cognitive abilities. Studies in children and adults have allowed differentiation of the effects of various commonly used antiepileptic agents. Maximal cognitive deficits are seen with. phenytoin, while phenobarbital and sodium valproate induce moderate disturbances, and carbamazepine seems relatively free from such toxicity. Further research is needed on the interrelationship between types of seizure disorders, types of anticonvulsant medications, and cognitive function.     

Effects of NMD A- and AMPA-Receptor Antagonists on Different Forms of Epileptiform Activity in Rat Temporal Cortex Slices

Summary: Lowering extracellular magnesium induces different patterns of epileptiform activity in rat hippocampus and entorhinal cortex. Short recurrent epileptiform discharges in the hippocampus are stable over time, whereas seizurelike events (SLEs) in the entorhinal cortex, the subiculum, and the neighboring neocortex develop into late recurrent discharges which are not blocked by clinically employed antiepileptic drugs. We tested the sensitivity of the different epileptiform discharge patterns to. /V-methyl-D-aspartate (NMDA)- and non-NMDA-receptor antagonists. As NMDA-receptor antagonist we used dextrorphan, ket-amine, and 2-aminophosphonovalerate (2APV); as α-amino-3-hydroxy-5-methyl-4-isoxazole-propionic acid (AMPA)-receptor antagonist we employed the quinoxaline derivative glutamate 6-cyano-7-nitroquinoxaline-2,3-dione (CNQX). The findings show that the different patterns of epileptiform activity, including the late recurrent discharges, are sensitive to all NMDA-receptor antagonists. However, when dextrorphan was employed to suppress seizure-like events, later recurrent discharges did not develop during the remaining time course of the experiment. CNQX reversibly suppressed recurrent discharges in the hippocampus and SLEs in the entorhinal cortex. However, late recurrent discharges become insensitive to CNQX, even at a high concentration of 60 μM m. This finding suggests a prominent role for NMDA receptors in the generation of late recurrent discharges.     

Pediatric Epilepsy Surgery

Summary: The use of implantable arrays of epidural electrodes has made it possible to carry out extraoperative electrocorticography (ECoG) and functional localization in the awake child. This has permitted cortical excisions that are determined by criteria similar to those obtained during surgical procedures performed under local anesthesia in adults. In addition, the method also permits simultaneous ECoG and video monitoring during the child's symptomatic seizures, providing additional important localizing information that is impractical to obtain in operations under local anesthesia. We report our experience with 75 children, ages 5 months to 15 years, whom we have managed with epidural electrode arrays. The method of extraoperative ECoG is described and illustrative cases are presented to demonstrate its feasibility and utility in children. In addition, we call attention to gliomas as a common cause of chronic focal seizures in children. Of 49 children undergoing resection and followed for from 1 to 14 years (mean of 5.8 years), 32 (65%) are either seizure free or have had a significant reduction in seizure frequency that has unambiguously improved their quality of life. The results are analyzed further by relating the surgical outcome to each of the pathologic entities that caused the seizures. This analysis reveals the variety of neurological conditions that commonly cause intractable focal seizure disorder in children and distinguishes those pathologic entities in which the seizure disorder is apt to respond to surgical intervention from those that will not.