医学人文的过去，现在和未来

医学人文经历了蓬勃发展的100年,其内涵不断丰富,研究方向不断拓展,为医学教育提供了巨大帮助。本文从医学人文的定义出发,梳理医学人文近100年来的学科发展史,重点回顾医学史、生命伦理学、医学人类学和叙事医学的发展历程,并通过分析医学人文运动背后的原因,阐述中国医学人文未来发展要求,以期促进我国医学人文领域开展更深入的研究与教育。     

See One, Do One, Teach One: Advanced Technology in Medical Education

The concept of "learning by doing" has become less acceptable, particularly when invasive procedures and high-risk care are required. Restrictions on medical educators have prompted them to seek alternative methods to teach medical knowledge and gain procedural experience. Fortunately, the last decade has seen an explosion of the number of tools available to enhance medical education: web-based education, virtual reality, and high fidelity patient simulation. This paper presents some of the consensus statements in regard to these tools agreed upon by members of the Educational Technology Section of the 2004 AEM Consensus Conference for Informatics and Technology in Emergency Department Health Care, held in Orlando, Florida. Findings: Web-based teaching: 1) Every ED should have access to medical educational materials via the Internet, computer-based training, and other effective education methods for point-of-service information, continuing medical education, and training. 2) Real-time automated tools should be integrated into Emergency Department Information Systems [EDIS] for contemporaneous education. Virtual reality [VR]: 1) Emergency physicians and emergency medicine societies should become more involved in VR development and assessment. 2) Nationally accepted protocols for the proper assessment of VR applications should be adopted and large multi-center groups should be formed to perform these studies. High-fidelity simulation: Emergency medicine residency programs should consider the use of high-fidelity patient simulators to enhance the teaching and evaluation of core competencies among trainees. CONCLUSIONS: Across specialties, patient simulation, virtual reality, and the Web will soon enable medical students and residents to... see one, simulate many, do one competently, and teach everyone.     

Medical Student Appraisal: Applications For Bedside Patient Education

Background

Medical students are often afforded the privilege of counselling patients. In the past resources were limited to pen and paper or anatomic models. The evolution of mobile applications allows for limitless access to resources that facilitate bedside patient education.

Objectives

To evaluate the utility of six applications in patient education and promote awareness of implementing mobile resources in clinical care.

Methods

Six medical students rotating on various clerkships evaluated a total of six mobile applications. Strengths, limitations, and suggested uses in clinical care were identified. Applications included Meditoons^TM, VisiblePatient^TM, DrawMD^TM, CardioTeach^TM, Visual Anatomy^TM, and 360° Patient Education SuiteTM. Data was generated from narrative responses supplied by each student during their evaluation period.

Results

Bedside teaching was enhanced by professional illustrations and animations depicting anatomy and pathophysiology. Impromptu teaching was facilitated, as resources were conveniently available on a student’s smartphone or tablet. The ability to annotate and modify images and subsequently email to patients was an extraordinary improvement in provider-patient communication. Universal limitations included small smartphone screens and the novelty of new technology.

Discussion

Mobile applications have the potential to greatly enhance patient education and simultaneously build rapport. Endless opportunities exist for their integration in clinical practice, particularly for new diagnoses, consent for procedures, and at time of discharge. Providers should be encouraged to try new applications and utilize them with patients.     

病人安全教育：21世纪医学教育的重要内容之一

病人安全是医学领域的永恒课题,也是医疗服务的最基本出发点和终极目标[1,2]。医学作为一门不确定的科学,必将导致不良事件和医疗差错的发生。促进病人安全,不仅是建立医疗质量保障与持续改进体系、和谐的医疗环境和病人安全文化氛围[3],更重要的是还应该从根本抓起,从本科医学教育着手,使医学生从进入医学院校起就学习病人安全知识,将＂病人安全＂意识整合到医疗服务的各个环节,防患于未然。     

Beyond the Medical Model: Thinking Differently about Medical Education and Medical Education Research

Abstract

Issue: In medical education, teaching is currently viewed as an intervention that causes learning. The task of medical education research is seen as establishing which educational interventions produce the desired learning outcomes. This ‘medical model’ of education does not do justice to the dynamics of education as an open, semiotic, recursive system rather than a closed, causal system. Evidence: Empirical ‘evidence’ of ‘what works’ – that is, what is supposed to affect ‘learning’ – has become the norm for medical educational improvements, where generalized summary outcomes of research are often presented as must-follow guidelines for myriad future educational situations. Such investigations of educational processes tend to lack an explicit engagement with the purposes of medical education, which we suggest to understand in terms of qualification (the acquisition of knowledge, skills, and understanding), socialization (becoming a member of the professional group) and subjectification (becoming a thoughtful, independent, responsible professional). In addition, investigations of educational processes tend to rely on causal assumptions that are inadequate for capturing the dynamics of educational communication and interaction. Although we see an increasing acknowledgement of the context-dependency of teaching practices toward educational aims, the currently prevailing view in medical education and educational research limits understanding of what is actually going on when educators teach and students participate in medical education – a situation which seriously hinders advancements in the field. Implications: In this paper, we hope to inform discussion about the practice of medical education by proposing to view medical education in terms of three domains of purpose (professional qualification, professional socialization, and professional subjectification) and with full acknowledgement of the dynamics of educational interaction and communication. Such a view implies that curriculum design, pedagogy, assessment, and evaluation should be reoriented to include and integrate all three purposes in educational practice. It also means that medical education research findings cannot be applied in just any teaching context without carefully considering the value of the suggested courses of actions toward the particular educational aims and teaching setting. In addition, medical educational research would need to investigate all three purposes and recognize the openness, semiotic nature, and recursivity of education in offering implications for teaching practice.     

18 Graduate Medical Education and Knowledge Translation: One Problem-Specific Approach in Residency

Traditional graduate medical education approaches to improving clinical performance based upon the latest research have included Journal Club and didactic lectures. Unfortunately, these educational interventions have rarely been demonstrated to change practice behavior or improve patient-important outcomes. Using a structured approach to identifying a gap between best-evidence knowledge and clinical practice, an illustrative one-year residency-wide translational research project was developed in a four year emergency medicine training program. Step one (assigned to the second year residents): identify and quantitatively justify a Knowledge Translation (KT) deficit within our institution. They identified steroids in adult bacterial meningitis as an unequivocal therapeutic option. Based upon a structured one-year chart review, they next demonstrated that only 7% of meningitis patients received pre-antimicrobial steroids. The next step (assigned to the first year residents): identify and quantify the physician "leaks" within the pipeline of information from publication to bedside utilization via an online survey. The third year residents hypothesized plugs for these information leaks, including examples of other specialties or institutions which have successfully navigated this specific clinical scenario. Finally, at an end-of-year Journal Club, the fourth year residents formulated a protocol for the appropriate use of steroids in suspected adult meningitis and brought together individuals from within the institution contributing to the best-practice leak. Knowledge Translation involves multiple stages beyond simple evidence awareness and usually involves continuation beyond the emergency department. The Washington University KT project offers a structured, multidisciplinary example of moving beyond contemplation to implementation of an unequivocal therapy.     

“No One Wants to Die Alone”: Incarcerated Patients' Knowledge and Attitudes About Early Medical Release

Context

Deaths among incarcerated individuals have steadily increased in the U.S., exceeding 5000 in 2014. Nearly every state has a policy to allow patients with serious life-limiting illness to apply for release from prison or jail to die in the community (“early medical release”). Although studies show these policies are rarely used, patient-level barriers to their use are unknown.

How To Develop A Low Cost, In-House Distance Learning Center For Continuing Medical Education

Continuing medical education is essential to improve the quality of health care. Residential courses are expensive for small hospitals but videoconferencing is an economical alternative. Models of distance learning centers are described along with an explanation of INTERNET basics and the use of INTERNET protocol for local area networks (INTRANET). Hardware, software and other technology required and the advantages and disadvantages of different communication methods are reported.     

The acute care for elders unit: taking the rehabilitation model into the hospital setting.

Older Americans are living longer than ever before. Those over the age of 65 years account for almost 13% of the population and one third of all hospitalizations. Older adults are much more likely than younger adults to develop complications during hospitalization. With the increasing number of older adults at higher risk of hospitalization, it is more important than ever to study and develop ways to minimize the cascade of dependency that can occur during hospitalization. The Acute Care for Elders unit model has been shown to improve the processes of hospital care, discharge outcomes, and the prevention of functional limitations for the acutely ill older adult.     

Tapping into the unimpossible: Philosophical health in lives with spinal cord injury

Background

We investigated the personal philosophies of eight persons with a tetraplegic condition (four male, four female), all living in Sweden with a chronic spinal cord injury (SCI) and all reporting a good life. Our purpose was to discover if there is a philosophical mindset that may play a role in living a good life with a traumatic SCI.

Methods

Two rounds of in-depth qualitative interviews were performed by the same interviewer, a philosophical practitioner by training (de Miranda). The second round systematically covered the following elements: bodily sense, sense of self, sense of belonging, sense of the possible, sense of purpose and philosophical sense. This six-step method developed by de Miranda is called SMILE_PH, an acronym for Sense-Making Interviews Looking at Elements of Philosophical Health.

Results

All the interviewees, as a consequence of their trauma, reported having gone through a reinvention of themselves which implied questioning the meaning and purpose of their life in particular and life in general. A philosophical rather than realistic sense of the possible was abstracted toward teleological growth. All interviewees developed a sense of purpose based on self-interested altruism and solidarity with disabled peers.

Conclusions

To reinvent a good life with SCI, in addition to physical training and willpower, one needs to consider philosophical questions about the self and life, what Kant called the cosmic interests of reason: What may I hope? What must I do? What can I know? Our results indicate that we should, in the future, explore what the philosophical health approach may bring to rehabilitation processes in the months or years that follow the trauma.     

Mock ECHO: A Simulation-Based Medical Education Method

Problem: This study was designed to develop a deeper understanding of the learning and social processes that take place during the simulation-based medical education for practicing providers as part of the Project ECHO® model, known as Mock ECHO training. The ECHO model is utilized to expand access to care of common and complex diseases by supporting the education of primary care providers with an interprofessional team of specialists via videoconferencing networks. Intervention: Mock ECHO trainings are conducted through a train the trainer model targeted at leaders replicating the ECHO model at their organizations. Trainers conduct simulated teleECHO clinics while participants gain skills to improve communication and self-efficacy. Context: Three focus groups, conducted between May 2015 and January 2016 with a total of 26 participants, were deductively analyzed to identify common themes related to simulation-based medical education and interdisciplinary education. Principal themes generated from the analysis included (a) the role of empathy in community development, (b) the value of training tools as guides for learning, (c) Mock ECHO design components to optimize learning, (d) the role of interdisciplinary education to build community and improve care delivery, (e) improving care integration through collaboration, and (f) development of soft skills to facilitate learning. Outcome: Mock ECHO trainings offer clinicians the freedom to learn in a noncritical environment while emphasizing real-time multidirectional feedback and encouraging knowledge and skill transfer. Lessons Learned: The success of the ECHO model depends on training interprofessional healthcare providers in behaviors needed to lead a teleECHO clinic and to collaborate in the educational process. While building a community of practice, Mock ECHO provides a safe opportunity for a diverse group of clinician experts to practice learned skills and receive feedback from coparticipants and facilitators.     

Homelessness in the Medical Curriculum: An Analysis of Case-Based Learning Content From One Canadian Medical School

Phenomenon: Homelessness is a major public health concern. Given that homeless individuals have high rates of mortality and morbidity, are more likely to be users of the healthcare system, and often report unmet health needs, it is important to examine how homelessness is addressed in medical education. We wanted to examine content and framing of issues related to homelessness in the case-based learning (CBL) curriculum and provide insights about whether medical students are being adequately trained to meet the health needs of homeless individuals through CBL. Approach: CBL content at a Canadian medical school that featured content related to homelessness was analyzed. Data were extracted from cases for the following variables: curriculum unit (e.g., professionalism/ethics curriculum or biomedical/clinical curriculum), patient characteristics (e.g., age, sex), and medical and social conditions. A thematic analysis was performed on cases related to homelessness. Discrepancies in analysis were resolved by consensus. Findings: Homelessness was mentioned in five (2.6%) of 191 CBL cases in the medical curriculum. Homelessness was significantly more likely to be featured in professionalism/ethics cases than in biomedical/clinical cases (p = .03). Homeless patients were portrayed as socially disadvantaged individuals, and medical learners were prompted to discuss ethical issues related to homeless patients in cases. However, homeless individuals were largely voiceless in cases. Homelessness was associated with serious physical and mental health concerns, but students were rarely prompted to address these concerns. Insights: The health and social needs of homeless individuals are often overlooked in CBL cases in the medical curriculum. Moreover, stereotypes of homelessness may be reinforced through medical training. There are opportunities for growth in addressing the needs of homeless individuals through medical education.     

迭代创新赋能新时代高层次复合型临床医学人才培养——以浙江大学医学院为例

新型冠状病毒肺炎疫情凸显了复合型医学人才缺乏的现状,纵观世界医学教育发展史,高层次复合型医学人才的培养愈发紧迫。锚定加快建设世界重要人才中心和创新高地的战略目标,本文以浙江大学医学教育为例,聚焦与探索新时代高层次复合型临床医学人才的培养模式,包括:(1)优化"非医本科、八年一贯、两段完整"的医学博士培养模式,创新临床医学课程体系;(2)创建临床医学博士后培养体系,整合优质人才和医疗资源的结构与布局,打造高品质学科交叉背景的师资队伍和创新策源地,不仅强化住院医师岗位胜任力和前沿交叉领域开拓潜力,而且保障高层次复合型临床医学人才的可持续发展。培养模式、课程体系、师资队伍和临床教学基地系列改革建设,迭代创新服务于面向世界科技前沿、面向经济主战场、面向国家重大需求、面向人民生命健康的新时代复合型高层次人才强国的战略。     

A national survey that needs to be repeated: Centre for the Advancement of Interprofessional Education

International policy has emphasized the development of interprofessional education (IPE) to reinforce interprofessional practice. This study explored the extent to which IPE initiatives in the UK are based on sound theoretical frameworks. Findings from semi-structured interviews with lead IPE curriculum developers at eight higher education institutions are presented which identified curriculum developers' developmental approaches to IPE. The findings reveal a notable lack of explicit theoretical basis for models of IPE. In many cases, senior managers determined the institutional approach to IPE which academic staff then needed to deliver. Curriculum developers reported adopting a largely practical approach to IPE curriculum development. However, questioning that focused on learning and teaching methods revealed that a range of learning theories was used implicitly. The significance of these findings is discussed with recommendations to inform future curriculum development of IPE initiatives.     

Medical Problems in Adults with Cerebral Palsy: Case Examples

The United Cerebral Palsy Association estimates that there are approximately one-half million adults with cerebral palsy in the United States. The number may be growing due to advances in medical care and the increased life expectancy of adults in general. Little has been published regarding their medical issues and rehabilitation needs. What little has been published has indicated almost a total neglect of specialty care and preventive medical services. Five case examples are presented to help illustrate particular medical and surgical problems not identified by either pediatric or adult healthcare providers alone. Each individual shows improvement with comprehensive team-oriented specialty care. Further study is encouraged.     

中山医学大学医学院如何推动问题导向学习

自1990年起,中山医学大学医学院根据办学的宗旨、世界医学教育改革的潮流及自身条件,选定推动问题导向学习(Problem-based learning;PBL-)、基础及临床课程整合(Integration of basic and clinical sciences)及成立教师成长中心(Center for Faculty Development;CFD)为本校教改之主轴。有关推动问题导向学习部分,历经(1)探索期(1994～2000):包括观察及学习国内外医学院校引入PBL的过程与经验。本期关键因素包括政府教改政策与评鉴指标,他校实施成果和本校改革决心与条件。(2)准备期(2000-2002):包括促成师生共识,小组老师之训练,教案之撰写与审查,课程整并与学生小组化安排。本期关键因素为教师间共识与其权益维护,课程整合及学习相关配合措施,并为医学预备科学生安排PBL先导课程(学习法与循证医学)。(3)实施期(2000～2004):包括选择高年级临床医学课程率先实施,学生与小组老师分组,实施时段与空间安排以及课程评价。本期关键因素在于实施小组学习的配套措施是否适当。(4)扩展期(2004-2006):将PBL自临床课程延伸至基础医学课程及医学人文课程。此期关键在于基础医学与人文课程老师的共识、教师训练与奖励措施,基础医学课程的整并及PBL计划的评价与改进。(5)精进期(2006～):预计建构PBL网络学习资源与规划在线实施PBL,并完成发展医学教育的器官化模块课程及其配套的PBL和临床技能训练。本校推动PBL的经验,认为PBL,是医学教育中良好的学习模式之一,可行性高且受到学生欢迎,但路途需步步为营,采取渐进改革,并争取老师与同学的认同是实施的关键。     

Medical Assistance in Dying: A Point of Care Educational Framework For Attending Physicians

Abstract

Issue: Medical assistance in dying (MAID) became legal in Quebec on December 10, 2015, and in the rest of Canada on June 17, 2016. This enabled 6,749 deaths through physician-assisted suicide or euthanasia between December 10, 2015 and October 31, 2018. While the death of a patient is a common experience for medical trainees, those that occur through MAID have unique features related to the methods, the timeline, the intended role of the physician in causing the death, and the request of the patient that initiates the process. These aspects necessitate a distinct approach to MAID medical education. Evidence: Despite the legalization of MAID in a growing number of jurisdictions, there is virtually no literature to guide MAID education in clinical practice. The cumulative evidence regarding the impact of patient death on medical students, residents, and attending physicians suggests a need for supported discussion and debriefing to process and reflect on the emotional experiences that follow patient death. This is especially important with MAID, in which there are unique ethical and psychological issues related to the physician’s direct role in causing the death of a patient. There is little published research on the impact such deaths have on physicians who provide MAID, or on others who are indirectly involved. However, there is evidence that learners desire MAID-specific education tailored to their unique needs. Didactic education about the medical and legal domains of MAID alone is insufficient to support learners’ needs. Experiential case-based learning with supervisory support has the potential to enhance training in end-of-life care in general, and specifically in MAID. The authors’ first clinical experience with a patient requesting MAID on an internal medicine clinical teaching unit (CTU) highlighted gaps in their preparedness to meet the associated professional and personal demands. Reflecting on these perceived gaps, and on the needs of learners identified in the literature on patient death and MAID education, the authors created a framework to guide learning at the point of care of a patient requesting MAID. Represented in a MAID Education Cogwheel and discussion guide, this framework specifies learning objectives and methods in six domains: medical, legal, moral, ethical, cultural, and psychosocial. Implications: Following a MAID request, attending physicians can use the framework to guide learners in ongoing conversations addressing these domains. Inter-professional participation can include such disciplines as psychiatry, palliative care, bioethics, pharmacy, nursing, physical and occupational therapy, social work, and spiritual care. Further research is necessary to test this framework to determine its’ feasibility, efficacy, and generalizability.     

No Worries, No Cares: An Investigation into Self-Reported "Nondistress" in College Students

An important methodological issue in depressionanalog research is whether individuals who scoreextremely low on self-report measures like the BeckDepression Inventory (BDI) should be included innondepressed control groups. Joiner, Schmidt, and Metalsky(1994) found that college students with BDI scores of 0or 1 evidenced a fake-good test taking style as measuredby the MMPI validity scales. The present study investigated whether very low BDI scores (BDI= 0 or 1; n = 21) might be associated with an elevatedpositive mood state, extreme optimism, positiveattributional style or social desirability. Resultsindicated that the very low scoring BDI subjects scoredhigher on social desirability than the low scoring group(BDI = 2 9, n = 63). Significant differences on mood,symptom and cognitive measures disappeared when social desirability was entered as a covariate.Findings support Kendall, Hollon, Beck, Hammen, andIngram's (1987) recommendation that subjects who score0 or 1 on the BDI should be excluded from a nondepressed control group.