教学督导会诊在超声医学科住院医师规范化培训中的应用

目的总结住院医师规范化培训阶段的会诊需求概况，评价教学督导会诊在住院医师规范化培训阶段的作用。 方法回顾性收集2015年8月至2017年8月间于北京协和医院超声医学科参加北京市住院医师规范化培训的住院医师43名及其于2017年11月至2018年8月申请教学督导会诊的病例，随访申请教学督导会诊的病例，总结会诊原因和部位，参照病理或临床诊断，对会诊医师作出教学评价（技术操作、定位、定性）。采用χ²检验比较不同年资、不同学历住院医师申请会诊原因和部位的差异，并采用t检验比较应用教学督导会诊前、后3年以下住院医师客观结构化临床考试（OSCE）阶段考核平均成绩的差异。 结果43名住院医师共随访1727份会诊病例。第一、二、三年住院医师申请会诊次数占比分别为53.0%（915/1727）、42.9%（741/1727）、4.1%（71/1727）。住院医师申请会诊原因：定性70.9%（1224/1727）、技术操作22.7%（392/1727）、定位6.4%（111/1727）。第一、二、三年住院医师因技术操作原因申请会诊比例分别为26.9%（246/915）、18.6%（138/741）、11.3%（8/71）；因定位原因申请会诊比例分别为7.8%（71/915）、4.5%（33/741）、9.8%（7/71）；因定性原因申请会诊比例分别为65.3%（598/915）、76.9%（570/741）、78.9%（56/71），不同年资住院医师申请会诊的原因不同，差异具有统计学意义（χ²=33.293，P＜0.001）。申请会诊的检查部位前三位为妇科27.9%（482/1727）、浅表器官23.3%（402/1727）和腹部20.1%（347/1727），共占71.3%，不同年资住院医师申请会诊的部位不同，差异具有统计学意义（χ²=167.583，P＜0.001）。第一、二年住院医师申请会诊主要为腹盆腔脏器技术操作和定性，第三年住院医师申请会诊集中在浅表器官病变的定性。不同学历住院医师申请会诊部位分布不同，差异具有统计学意义（χ²=64.942，P＜0.001），申请会诊原因分布差异无统计学意义（χ²=8.131，P=0.087），平均申请会诊次数相近。97.7%（383/392）的技术操作问题通过教学督导会诊得到解决；教学督导会诊定位正确率73.0%（81/111）；定性正确率92.7%（1135/1224）。应用教学督导会诊后的住院医师OSCE成绩高于应用前［（85.7±6.6）分vs（75.7±7.5）分］，差异具有统计学意义（t=-2.426，P=0.036）。 结论随着住院医师年资增加，申请会诊次数减少。不同年资住院医师申请会诊的部位和原因不同。住院医师因技术操作原因申请会诊次数逐年下降，定性需求逐年增加。教学督导会诊能有效帮助住院医师解决技术操作难点、定位和定性，提升住院医师临床胜任力。

Application of teaching supervision consultation in standardized medical training of residents in ultrasound department

ObjectiveTo summarize the consultation needs of residents and assess the role of teaching supervision consultation in the standardized medical resident training stage. MethodsResidents (n=43) receiving training at ultrasound department of Peking Union Medical College Hospital from August 2015 to August 2017 and cases that were consulted by these residents from November 2017 to August 2018 were included. The reasons and examination sites for consultation were summarized and teaching evaluation (technical operation, positioning, and qualitative diagnosis) was assessed on the consultant according to the pathological or clinical diagnosis. The χ² test was used to compare differences in reasons and sites for consultation by residents with different seniority or educational backgrounds, and the average scores of objective structured clinical examination (OSCE) for residents with less than 3 years of experience before and after teaching supervision consultation were compared. ResultsA total of 1727 consultation cases were followed by the 43 residents. The number of consultation times accounted for 53.0% (915/1727), 42.9% (741/1727), and 4.1% (71/1727) for the first-, second-, and third-year residents, respectively. Reasons for consultation were technical operation 70.9% (1224/1727)], positioning 22.7% (392/1727)], and qualitative diagnosis 6.4% (111/1727)]. In the first-, second- and third-year residents, the percentages of residents applying for consultation were 26.9% (246/915), 18.6% (138/741), and 11.3% (8/71) for technical operation reasons; 7.8% (71/915), 4.5% (33/741), and 9.8% (7/71) for positioning reasons; and 65.3% (598/915), 76.9% (570/741), and 78.9% (56/71) for qualitative reasons, respectively; there was a significant difference in the consultation reasons between residents with different seniority (χ²=33.293, P＜0.001). The top three examination sites that were applied for consultation were gynecological 27.9% (482/1727)], superficial 23.3% (402/1727)], and abdominal organs 20.1% (347/1727)], accounting for 71.3% of all examination sites; there was a significant difference in the consultation sites between residents with different seniority (χ²=167.583, P＜0.001). The main reasons for consultation in junior residents were qualitative analysis and the technical operation of abdominal and pelvic organs, while for senior residents, qualitative analysis of superficial lesions was the main reason. The distribution of consultation sites applied by residents with different educational backgrounds was significantly different (χ²=64.942, P＜0.001), while there was no significant difference in the distribution of consultation reasons (χ²=8.131, P=0.087). The average number of consultation times was similar for residents with different educational backgrounds. Approximately 97.7% (383/392) of the technical operation problems were solved through consultation. The accuracy of consultant for positioning and qualitative diagnosis was 73.0% (81/111) and 92.7% (1135/1224), respectively. The residents' OSCE score after teaching supervision consultation was significantly higher than that before teaching supervision consultation (85.7±6.6 vs 75.7±7.5, t=-2.426, P=0.036). ConclusionWith the increase in the seniority of residents, the frequency of consultation decreases. The consultation reasons and sites are different among residents with different seniority. The number of residents applying for consultation due to technical operation is decreasing while the qualitative demand is increasing year by year. Teaching supervision consultation proves to be effective in helping residents solve technical operation difficulties and determine the location and nature of lesions, and improving the clinical competence of residents.