住院医生如何进行临床教学

住院医生教学是医院临床教学的重要组成部分,他们的参与程度是医学生见习及实习阶段临床教学质量的保证。住院医生在医学教学生过程中,不仅能进一步提高自身的教学能力,又能不断发现并弥补自身的知识缺陷。住院医生的临床教学重点在训练临床基本技能、培养良好临床习惯、医患沟通及传授职业精神。了解及掌握临床教学技巧能提高住院医生教学兴趣及教学质量。     

Evaluation of a teaching workshop for residents at the University of Saskatchewan: a pilot study.

PURPOSE: The University of Saskatchewan College of Medicine in Saskatoon, Canada, has been running a two-day workshop for teachers since 1993 to which both faculty and residents had been invited. Although the design of the workshop is consistent with principles of adult learning, it was important to determine if the workshop effectively helped residents to acquire and then use key teaching skills in real-world situations where they were called on to organize and make presentations. METHOD: This study, conducted in 1998 and 1999 with residents only, used a randomized controlled experiment with third-party ratings of before and after videotaped teaching sessions done in actual performance settings. There were eight residents each in the control and intervention groups. RESULTS: The intervention group made statistically significant and positive changes in two key areas taught in the workshop and showed slight improvement in a third. The changes made by the residents in the intervention group were in presenting the opening "set" (41.4% absolute improvement) and the use of instructional objectives (11.5%). The "body" of their teaching sessions increased slightly (9.3%). The control group held relatively stable. CONCLUSION: While this study demonstrates that the workshop likely made a difference in the teaching performance of the intervention group, the small sample size (eight in each group) and the presence of confounding variables suggest that further research should be conducted.     

Listening to music: the case for its use in teaching medical humanism.

Listening to music has rarely been used by educators as a tool to teach humanism to medical students and residents. The authors present the argument that music embodies the characteristics of medical humanism (i.e., caring, empathy, human dignity, compassion, and the fostering of relationships) and that listening to music is ideally suited for inclusion in a humanism curriculum. The authors also describe an eight-session "music and medicine" course for residents given at their institution as part of an ongoing humanism-in-medicine initiative. The results of a post-course survey given to the participants showed that residents valued the course as an academically valid approach to humanism training.     

Using children as simulated patients in communication training for residents and medical students: a pilot program.

Medical schools are charged with the challenge of teaching effective communication skills, a core competency for residents and medical students. Especially challenging is the task of developing effective methods for training residents and students to communicate with children with mental health issues. The authors describe a pilot program at Mercer University School of Medicine that used pediatric standardized patients (SPs), ages 9-19, to aid in training residents and medical students in complex interviewing skills addressing mental health issues. New curriculum components for four pediatric problems, anorexia nervosa, depression, separation anxiety, and attention deficit hyperactivity disorder (ADHD), were designed and implemented by the authors in 2002-04. The training sessions were evaluated by the participating SPs as well as the residents and medical students in training. The components of the training were a lecture and subsequent practice using pediatric SPs and adults acting as their mothers. Evaluation included the qualitative analysis of SPs' reactions to participation in the training as described during a posttraining-session focus-group, as well as questionnaire responses by residents and medical students. The children role-playing the scenario of a difficult-to-manage situation and their adult "parent" actors voiced strongly positive reactions to participating in training residents and medical students. The reactions of physicians in training were also positive. The authors thus conclude that child and adolescent actors can be effectively used as SPs to train residents and students in complex interviewing skills, even in cases involving children with challenging mental health issues.     

“三步法”微创模拟教学技术在泌尿外科临床教学中的应用

目的探讨微创模拟教学技术在泌尿外科临床教学中的应用效果。方法针对实习医生、进修医生以及低年资住院医生的3个层次人群,每组6人,采用"微创技术理论知识学习+仿真模拟教学训练+临床微创手术操作"的三步法新教学模式进行培训;对3组学员培训前后基础理论、操作技能和手术实践进行考核并对结果进行对比分析。结果培训后3组学员微创基础理论和操作技能较培训前均得到显著提升(P0.05),进修医生以及低年资住院医生可完成简单的泌尿外科微创技术手术。建立了完善的泌尿外科标准化临床微创教学培训流程。结论微创模拟教学技术为临床医生和医学生提供了一种安全和高效的学习培养方法,可快速提高泌尿外科年轻医师微创手术的临床技能,缩短学习曲线。     

Development of a blended communication training program for managing medically unexplained symptoms in primary care using the intervention mapping approach

BackgroundGeneral practice (GP) training in how to communicate with patients with medically unexplained symptoms (MUS) is limited.ObjectiveDevelopment, implementation and evaluation of an evidence-based communication training program for GP residents focused on patients with MUS in primary care.MethodsWe used the intervention mapping (IM) framework to systematically develop the MUS training program. We conducted a needs assessment to formulate change objectives and identified teaching methods for a MUS communication training program. Next, we developed, implemented and evaluated the training program with 46 residents by assessing their self-efficacy and by exploring their experiences with the training.ResultsThe resulting program is a blended training with an online course and two training days. After attending the training program, GP residents reported significantly higher self-efficacy for communication with patients with MUS at four weeks follow up compared to baseline. Furthermore, GP residents experienced the training program as useful and valued the combination of the online course and training days.Conclusion and practice implicationsWe developed an evidence-based communication training program for the management of patients with MUS in primary care. Future research should examine the effect of the training on GP residents’ communication skills in MUS consultations in daily practice.     

独立值班考核制度在内科住院医师规范化培训中的应用

目的介绍北京协和医院内科创立的独立值班考核制度,分析该考核制度在住院医师独立值班能力评价和分层中的作用。方法对北京协和医院内科2017年和2018年内科住院医师独立值班考核的结果进行统计,分析不同来源的住院医师在考试次数、通过考试所需时间和通过率方面的分布。结果内科临床医学博士后、专业型临床硕士研究生和北京市基地规培住院医师在通过独立值班考核所需次数方面无差异;内科临床博士后通过考核用时最短,专业型临床硕士研究生次之,北京市规培住院医师用时最长(χ^2=96.27,P<0.05),可以进行初步分层;通过临床带教,大部分住院医师都能在实习6个月内通过独立值班考核,承担独立值班工作。结论在内科住院医师规范化培训中,独立值班考核制度能够客观评价住院医师的值班能力,最大限度的保证临床安全。北京市基地规培住院医师通过考核时间较长,应注意加强临床教学、提高学员能力。     

Psychosocial training in U.S. internal medicine and family practice residency programs.

PURPOSE: Competence in the psychosocial aspects of medical care is necessary for primary care physicians to function effectively. This study investigated the psychosocial training internal medicine and family practice residents receive in U.S. programs. METHODS: In 1996, program directors of all U.S. internal medicine (IM) and family practice (FP) residency programs were surveyed regarding the format, content, and quantity of psychosocial training provided in their programs, their opinions on topics related to psychosocial training, and demographics of their programs. RESULTS: The response rate was 61%. Ninety-nine percent of FP and 62% of IM program directors reported requiring at least one psychosocial training experience. Family practice programs required an average of 352 hours (SD +/- 175; range 27-2,664) of psychosocial training compared with 118 hours (SD +/- 272; range 0-1,050) for IM programs. Most IM and FP program directors expected residents to achieve at least basic competency in virtually all psychosocial topic areas; however, FP programs provided a greater range of psychosocial experiences. FP program directors most often identified psychologists and IM program directors most often identified internists as providing the most psychosocial training in their programs. Both IM and FP program directors considered lack of curricular time to be the main obstacle to development of psychosocial training. CONCLUSION: Residents' competence in psychosocial areas is important to both IM and FP program directors. However, content and time devoted to psychosocial training vary considerably both within and between program types.     

提高口腔颌面外科研究生显微操作实验课教学质量的体会

进行临床前显微外科操作培训,培养专科研究生显微操作能力与临床实践结合,是目前口腔颌面外科显微操作训练的目标和指导思想。本文介绍我院口腔颌面外科开展的专科研究生显微解剖理论学习和操作实践训练及专科研究生显微操作技能培养,探讨临床前医学教学模式的改革,旨在探索并建立以学生为中心的教学模式,将以往单向传授知识的临床前技能培训的传统模式变为多途径多媒体引导专科研究生主动学习知识掌握核心技能的新模式,有利于学生迅速掌握显微外科技能,尽快与临床接轨。     

A new paradigm for teaching behavior change: Implications for residency training in family medicine and psychiatry

ABSTRACT: BACKGROUND: Primary care physicians (PCPs) provide ~50 % of all mental health services in the U.S. Given the widening gap between patient mental health needs and resources available to meet those needs, there is an increasing demand for family medicine and psychiatry trainees to master competencies in both behavioral medicine and primary care counseling during residency-if for no other reason than to accommodate the realities of medical practice given the oft present gap between the need for psychiatric services and the availability, quality, and/or affordability of specialized psychiatric care. To begin to address this gap, a skills-based, interactive curriculum based on motivational interviewing (MI) as a teaching method is presented. METHODS: The curriculum described in this paper is a four-week block rotation taught in the second year of residency. Motivational interviewing (MI) is used as a teaching approach toward the goal of clinical behavior change. Residents' strengths, personal choice and autonomy are emphasized. Each week of the rotation, there is a clinical topic and a set of specific skills for mastery. Residents are offered a "menu" of skills, role modeling, role/real play, practice with standardized patients (SP), and direct supervision in clinic. RESULTS: Thirty-nine residents have completed the curriculum. Based on residents' subjective reporting using pre-post scales (i.e., importance and confidence), all participants to date have reported substantial increases in confidence/self-efficacy using primary care counseling skills in their continuity clinic. CONCLUSIONS: This paper presents an innovative, empirically based model for teaching the essential skills necessary for physicians providing care for patients with mental/emotional health needs as well as health-behavior change concerns. Implications for training in the broader context, particularly as it relates to multi-disciplinary and collaborative models of teaching/training are discussed.     

Anxiety and anger among family practice residents: a South Carolina family practice research consortium study.

PURPOSE: To study the dimensions of anxiety and anger experienced by a statewide sample of South Carolina family practice residents. METHOD: A total of 350 family practice residents from seven programs participated. Each resident completed the Beck Depression Inventory, the State-Trait Anxiety Inventory, the Profile of Mood States, the Hassles Scale, the Maslach Burnout Inventory, and the State-Trait Anger Expression Inventory (STAXI) on at least one occasion. We analyzed reported anxiety and anger by gender, year of training, race, marital status, type of program (community hospital versus university), location of program, and season of the year. RESULTS: Residents reported lower levels of anxiety and anger across most dimensions compared with the adult populations on which the tests were standardized and with other resident and practicing physician populations. The residents did not demonstrate excessive levels of anger as a trait or in response to situations, nor did they significantly suppress anger. Although the residents reported a higher frequency of hassles than did normal populations, they did not consider these hassles severe. A higher than normal level of depersonalization was found among male, Caucasian, and third-year residents. CONCLUSIONS: These family medicine residents did not experience excessive levels of anxiety or anger during residency training either as a trait, state or somatic response. Extensive social and emotional "in-house" support, attention to stress-management skills, and the moderate personality characteristics of family practice residents help explain these findings. Initial assessment of psychological functioning and early remediation and program support during training may significantly reduce the potential for residents' impairment.     

Internal medicine and family practice. Controversies, conflict and compromise.

Internal medicine and family practice have come into conflict because both specialties consider primary care to be part of their "turf". Moreover, in academic medical centers there is competition for scarce resources, including patients and support for residents. Analysis of the number of physicians in practice as well as in training shows clearly that both internists and family physicians, as well as pediatricians and obstetricians, must participate in rendering primary care if the needs for this type of physician are to be met. Internal medicine also has to achieve a better balance between generalists and subspecialists, and family practice must define its limitations, monitor its rapid growth and assure the quality of its training programs. Most of these problems are internal to each speciality rather than between two specialties, and, where there is conflict, compromise is clearly possible.     

Psychosomatic medicine, behavioral medicine, just plain medicine

Neurally mediated physiologic responses fulfill all of the criteria for behavior and obey all of the laws of behavior subject to the anatomic and physiologic constraints inherent in their structures and functions. It is illogical and wrong to assert that neurally mediated responses interact with behavior. THEY ARE BEHAVIOR. These principles are a legitimate and necessary part of the training of all medical students, residents, and fellows. The conceptual basis of psychosomatic practice does not need to be derived from the dualistic notions of psychoanalysis or from the dualistic notions of biobehaviorism. Psychosomatic medicine is an integral aspect of medical practice. It needs to exist because people act and react differently from one another, and because the same person acts and reacts differently from one situation to another. Psychosomatic medicine is not psychiatry in medicine. Each of the specialties and each of the subspecialties encounters its own set of psychosomatic problems; and treatment strategies to resolve these problems need to be integrated into the clinical practice of that discipline.     

临床技能培训规范在妇科肿瘤学教学中的应用

临床技能培训是提高临床教学质量的重要内容,而建构针对性较强的临床技能培训规范则是提高妇科肿瘤学临床教学质量的关键环节。昆明医科大学第三附属医院妇瘤科,采用"知群体-建规范-重思路-提要求"的"四步走"策略进行培训,既有利于学生"三基"的融会贯通,激发学生学习妇科肿瘤学临床技能的主动性;又有利于任课教师在临床技能培训中拓展思维,调动带教的积极性。该方法为妇科肿瘤学临床技能规范培训提供了一种新途径。     

The relationship of residents' autonomy and use of a teaching hospital's resources

This 1990 study examines the relationship between the degree of use of patient care resources and the degree of supervision of residents by attending physicians (as perceived by residents) at a large midwestern teaching hospital. Ratings of the degree of clinical autonomy allowed residents by 65 attending physicians--each of whom had a general internal medicine practice with a significant hospital component--were provided by 23 former internal medicine chief residents and 17 internal medicine residents who were in their third year at the time of the study. A regression model was used to test the association between hospital resource use (as shown by total hospital charges to patients and their lengths of stay) and the residents' mean ratings of the degrees of autonomy the attending physicians permitted residents, for 7,169 of these physicians' patients discharged between 1986 and 1989 in 28 diagnosis-related groups. The analysis was controlled for patients' insurance status and chronic disease comorbidities. The patients whose attending physicians were rated as allowing substantial clinical autonomy had significantly lower total charges and lengths of stay (p less than .0001). These results suggest that internal medicine residents have an inherently conservative practice style that values low-intensity workups and rapid discharge of patients.     

Addressing the problems associated with general practitioners'' workload in nursing and residential homes: findings from a qualitative study.

BACKGROUND: Caring for older people in residential and nursing homes makes major demands on general practitioners (GPs). AIM: To investigate the perceptions and experiences of home managers and GPs of the provision of general medical services for older residents. DESIGN OF STUDY: In-depth qualitative study. SETTING: Forty-two nursing and residential homes in five locations in England, interviewing home managers and eight of their residents' GPs. METHOD: Semi-structured face-to-face and telephone interviews. RESULTS: Most homes endorse principles of continuity of care and patient choice. Although many homes therefore deal with a large number of GPs, with the inherent difficulties of coordinating care and duplication of GP effort, limitations in residents' choice of GP result in the majority of residents in many homes being registered with only one or two practices. Contracts between homes and GPs may provide opportunities for improving medical care but do not guarantee additional services and have implications for patient choice and residents' fees. Visits on request form the bulk of GPs' workload in homes but can be hard to obtain for residents and may not be appropriate. Regular weekly surgeries are preferred by many homes but may have additional workload implications for GPs. CONCLUSION: The assumption that patient choice and continuity in medical care are paramount for older people in nursing and residential homes is questioned. While recognition of the additional workload for GPs working in these settings is necessary, this should be accompanied by additional NHS remuneration. Further research is urgently required to identify which models of GP provision would most benefit both residents and GPs.     

An advanced communication skills course for fourth-year, post-clerkship students.

OBJECTIVE: A novel five-module advanced communication skills course entitled "Doctor-Patient Relationships" was planned and implemented in 2000-01 at the University of British Columbia (UBC). The course was part of the final four-month component of the new MD undergraduate program: Effective Skills for Medical Practice. The goals of the communication skills course were to (1) address problems experienced by the students so far; (2) address deficiencies in achieving the UBC exit competencies; (3) help the students pass the Medical Council of Canada examinations, in particular objectives related to the Considerations of the Legal, Ethical, and Organizational aspects of the practice of medicine (CLEO); and (4) help students prepare for their roles beyond undergraduate medicine (residency, independent practice). DESCRIPTION: The course was developed by an interdisciplinary team (family practice, pathology, pediatrics, psychiatry, surgery) with input from students. The broad strengths and weaknesses of their communication skills training were identified by seven third-year medical students who kept logs over the course of their clinical clerkships to document their learning of communication skills. Analysis of these logs plus feedback meetings with the students revealed attitudinal and skills issues that needed to be addressed in the new course. The goals and principles of the course were in part agreed upon by focus groups with students, attended by faculty observers, to ensure their relevance to students. The first module "Beyond the Mask: Surviving and Thriving in Residency Training" is designed to focus students' attention on the personal relevance of developing excellence in communication skills in preparation for residency training. It includes a video of residents talking about their experiences of communication problems to trigger reflection and discussion. In the remaining four modules the students are required to put communication skills together with their medical knowledge. Each module includes pre-readings, video demonstrations (in sessions 4 and 5), practice with standardized patients (total of 14 scenarios) and structured feedback from SPs, students, and tutor. The themes of the sessions are "Dealing with Emotionally Challenging Patient Situations (informing about bad news), "Compliance and Patient Information," "Informed Consent and Shared Decision Making," and "Difficult Physician-Patient Encounters." Each module lasts two hours. The course was implemented for 120 students, facilitated by 14 tutors (seven to eight students per group). DISCUSSION: Student involvement in many different ways provided an important reality check and made us think about how to present the new course so that it was relevant and interesting to students. Attention to student input was a major contributor to the good evaluations given the course. Students rated the course highly: the relevance of the weekly themes was rated 4.21 on a five-point scale; the effectiveness of the SP interviews, 4.10; the effectiveness of the group discussion and feedback, 4.18; and overall course effectiveness in enhancing communication skills, 3.91. The tutors also rated the course highly, and the students rated the tutors highly. Minor changes will be made to the course next year based on the specific suggestions for improvement, which were identified.     

Marrying content and process in clinical method teaching: enhancing the Calgary-Cambridge guides.

Communication skills training is now internationally accepted as an essential component of medical education. However, learners and teachers in communication skills programs continue to experience problems integrating communication with other clinical skills, ensuring that clinical faculty support and teach communication beyond the formal communication course, extending communication training coherently into clerkship and residency, and applying communication skills in medical practice at a professional level of competence. One factor contributing to these problems is that learners confront two apparently conflicting models of the medical interview: a communication model describing the process of the interview and the "traditional medical history" describing the content of the interview. The resulting confusion exacerbates the above dilemmas and interferes with learners using communication skills training to advantage in real-life practice. The authors propose a comprehensive clinical method that explicitly integrates traditional clinical method with effective communication skills. To implement this more comprehensive approach, they have modified their own Calgary-Cambridge guides to the medical interview by developing three diagrams that visually and conceptually improve the way communication skills teaching is introduced and that place communication process skills within a comprehensive clinical method; devising a content guide for medical interviewing that is more closely aligned with the structure and process skills used in communication skills training; and incorporating patient-centered medicine into both process and content aspects of the medical interview. These enhancements help resolve ongoing difficulties associated with both teaching communication skills and applying them effectively in medical practice.     

Behavior and behavioral determinants in the management of demented people in residential homes

The major goal of this Dutch study was to compare the behavior of staff towards demented patients in residential homes with five expert recommendations for dealing with dementia. There were 136 respondents in this postal survey. The results showed that the staff carried out the recommendations of encouraging activity, establishing effective communication, and not changing the routine of the patient's physical environment without good reason. However, the staff tested and corrected the residents too often. This was related to insufficient knowledge and a lack of support from colleagues. It is recommended that staff receive specific training during and after their professional training.