舒缓医学教育在老年医学专业教学中的实践

本文介绍了国内外舒缓医学发展历史,调研了舒缓医学教学在老年医学中存在的问题;对改善老年医学舒缓医学教育进行探索,采用理论授课、临床实习（PBL教学、案例教学及叙事医学教学）等开展老年医学专业研究生舒缓医学教育。结果表明,67.9%的学生增加了舒缓医学的学习感,92.5%的学生认为舒缓医学非常重要,75%的学生认为增强了语言表达能力、与患者晚期疾病沟通能力即临终关怀能力。     

Physician interpretations and textbook definitions of blinding terminology in randomized controlled trials

CONTEXT: When clinicians assess the validity of randomized controlled trials (RCTs), they commonly evaluate the blinding status of individuals in the RCT. The terminology authors often use to convey blinding status (single, double, and triple blinding) may be open to various interpretations. OBJECTIVE: To determine physician interpretations and textbook definitions of RCT blinding terms. DESIGN AND SETTING: Observational study undertaken at 3 Canadian university tertiary care centers between February and May 1999. PARTICIPANTS: Ninety-one internal medicine physicians who responded to a survey. MAIN OUTCOME MEASURES: Respondents identified which of the following groups they thought were blinded in single-, double-, and triple-blinded RCTs: participants, health care providers, data collectors, judicial assessors of outcomes, data analysts, and personnel who write the article. Definitions from 25 systematically identified textbooks published since 1990 providing definitions for single, double, or triple blinding. RESULTS: Physician respondents identified 10, 17, and 15 unique interpretations of single, double, and triple blinding, respectively, and textbooks provided 5, 9, and 7 different definitions of each. The frequencies of the most common physician interpretation and textbook definition were 75% (95% confidence interval [CI], 65%-83%) and 74% (95% CI, 52%-90%) for single blinding, 38% (95% CI, 28%-49%) and 43% (95% CI, 24%-63%) for double blinding, and 18% (95% CI, 10%-28%) and 14% (95% CI, 0%-58%) for triple blinding, respectively. CONCLUSIONS: Our study suggests that both physicians and textbooks vary greatly in their interpretations and definitions of single, double, and triple blinding. Explicit statements about the blinding status of specific groups involved in RCTs should replace the current ambiguous terminology.     

Patients' knowledge of options at the end of life: ignorance in the face of death

CONTEXT: Effectiveness of legislation promoting advance directives and legalizing physician-assisted suicide depends on patients' understanding their legal options about end-of-life care. However, outpatients' understanding of their legal options at the end of life has not been studied. OBJECTIVES: To estimate the percentage of outpatients who are informed about 4 areas relevant to end-of-life care: refusal and withdrawal of lifesaving treatments, physician-assisted suicide, active euthanasia, and double effect; and to determine whether authoring advance directives, experiencing illness, acting as a proxy for health care decisions, and caring for an ill loved one are associated with better knowledge in end-of-life care. DESIGN: Cross-sectional survey. SETTING AND PARTICIPANTS: One thousand consecutive English-speaking, adult patients attending 1 university-based internal medicine clinic and 3 community-based, university-affiliated, mixed internal medicine and family practice clinics in Oregon during May and June 1999. MAIN OUTCOME MEASURES: Percentage of correct responses in the 4 topic areas and total knowledge score, adjusted for demographic (eg, age, race, educational level, income level, marital status) and experiential (eg, health, proxy decision making, advance directives, and death of a loved one) factors. RESULTS: Of the 1000 patients invited to participate, 728 (73%) consented and completed the questionnaire and were included in the analysis. A total of 69% of respondents answered correctly regarding refusal of treatment, 46% for withdrawal of treatment, 23% for assisted suicide, 32% for active euthanasia, and 41% for double effect. Sixty-two percent of respondents did not distinguish between assisted suicide and euthanasia. After adjustment for other covariates, better knowledge was significantly associated with white race (odds ratio [OR], 2.3; 95% confidence interval [CI], 1.3-4.2), having at least a college degree (OR, 3.0; 95% CI, 1.4-6.7), and having been a proxy for health care decisions (OR, 1.8; 95% CI, 1.2-2.6). Personal experience with illness (OR, 1.0; 95% CI, 0.6-1.5), death or illness of a loved one (OR, 1.6; 95% CI, 1.0-2.7), and authoring an advance directive (OR,1.3; 95% CI, 0.9-2.0) were not associated with better knowledge. CONCLUSIONS: A significant proportion of outpatients at university-affiliated clinics in Oregon appear to misunderstand options in end-of-life care. Our results suggest that greater public knowledge about end-of-life care is needed, and advance care planning must be preceded by education about options in end-of-life care. JAMA. 2000;284:2483-2488.     

Quality of care for patients with rheumatoid arthritis

CONTEXT: Patients with rheumatoid arthritis are at risk for substantial morbidity because of their arthritis and premature mortality due to comorbid diseases. However, little is known about the quality of the health care that these patients receive. OBJECTIVE: To assess the quality of the health care that rheumatoid arthritis patients receive for their arthritis, comorbid diseases, and health care maintenance and to determine the effect of patterns of specialty care on quality. DESIGN, SETTING, AND PARTICIPANTS: Historical cohort study of 1355 adult rheumatoid arthritis patients enrolled in the fee-for-service or discounted fee-for-service plans of a nationwide US insurance company. Patients were identified and followed up through administrative data between 1991 and 1995. MAIN OUTCOME MEASURES: Quality scores for arthritis, comorbid disease, and health care maintenance were developed from performance on explicit process measures that related to each of these domains and described the percentage of indicated health care processes performed within each domain during each person-year of the study. RESULTS: During 4598 person-years of follow-up, quality scores were 62% (95% confidence interval [CI], 61%-64%) for arthritis care, 52% (95% CI, 49%-55%) for comorbid disease care, and 42% (95% CI, 40%-43%) for health care maintenance. Across domains, care patterns including relevant specialists yielded performance scores 30% to 187% higher than those that did not (P<.001) and 45% to 67% of person-years were associated with patterns of care that did not include a relevant specialist. Presence of primary care without specialty care yielded health care maintenance scores that were 43% higher than those for patterns that included neither primary nor relevant specialty care (P<.001). CONCLUSIONS: In this population, health care quality appears to be suboptimal for arthritis, comorbid disease, and health care maintenance. Patterns of care that included relevant specialists were associated with substantially higher quality across all domains. Patterns that included generalists were associated with substantially higher quality health care maintenance than patterns that included neither a generalist nor a relevant specialist. The optimal roles of primary care physicians and specialists in the care of patients with complex conditions should be reassessed. JAMA. 2000;284:984-992     

老年住院患者衰弱综合征现状及影响因素

 目的  老年住院患者衰弱综合征现状, 探讨其影响因素。方法  采用方便抽样法选取上海市某三甲医院外科、内科、老年科老年住院患者279例, 采用一般资料调查表、衰弱问卷式评分表(Frail scale)、基础疾病调查表研究衰弱的发生情况, 分析临床资料与衰弱程度的关系。结果  65岁以上住院老年人群衰弱前期的发生率为41.2%, 衰弱发生率为34.4%; 衰弱前期与衰弱期的高发年龄分别为65～70岁(27.0%)和86～90岁(34.4%)。衰弱程度与年龄、文化程度、家庭人均月收入、握力的比较差异具有统计学意义(P<0.01)。有序Logistic回归分析显示, 关节炎、脑卒中、慢性肺疾病与衰弱程度比较的结果具有统计学意义(P<0.05), 关节炎、脑卒中、慢性肺疾病患者的衰弱发生率通常是无关节炎、脑卒中、慢性肺疾病患者的6. 9、6. 0、2. 7倍。结论  老年住院患者衰弱综合征受多种因素影响, 与多种不良结局相关, 可作为医护人员提高老年护理质量的参考依据。     

217例老年精神病人的躯体共病性研究

目的：探讨老年精神科病人躯体疾病共病情况及其意义。方法：调查217例老年精神科病人的精神科诊断及合弄躯体疾病情况。结果：88．9％的病人合并有躯体疾病，每一个病人合并的躯体疾病的病种数平均为2．18种。合并的躯体疾病多见的是脑血管病、高血压、心脏病、感染、糖尿病、慢性阻塞性肺疾病（COPD）等。结论：老年精神科病人的躯体共病现象具有普遍性，其躯体疾病分布具有普通老年科病人的特点。躯体共病影响精神疾病的疗效预后及老年精神科的临床工作模式。     

临床路径在血液科临床教学中的应用评价

目的：探讨基于临床路径的教学方法在血液科临床带教中的实施效果．方法将在血液科实习的本科生按照来科实习顺序非随机分组,实验组在教学过程中加入特发性血小板减少性紫癜（idiopathic thrombocy-topenic purpura,ITP）临床路径作为教学工具,对照组以内科学第七版本科教材为基础进行教学,每组学生实习2周后出科时进行口头考试,并设计调查问卷进行现场调查．结果本研究中接受ITP临床路径培训的实验组共纳入32名实习医生,以内科学第七版教材为基础的对照组共纳入38名实习医生．2组间实习同学对ITP“病史询问要点、诊断标准和鉴别诊断的把握、实验室检查项目的选择”差异有统计学意义（P＜0.01）,实验组得分优于对照组;2组间关于“首选治疗方案问题”方面差异无统计学意义（P＞0.05）;但是对于“首选激素治疗2周内血小板计数仍低于20×109/L的患者下一步治疗”方面,对照组得分优于实验组（P＝0.0003）．调查问卷的结果显示临床路径组实习学生对于ITP临床教学方法的接纳程度为93.8%,开放式问题调查显示临床路径教学更为直观简洁,有利于实现标准化教学．结论将临床路径作为血液科实习医生的教学工具之一有利于学生更为清楚地理解该病种的诊治,具有可操作性,但需要结合教材进行深入讲解．     

Home care services as teaching sites for geriatrics in family medicine residencies

Evaluating the physical and psychological constitution of elderly patients and their social and cultural environments requires skills that should be taught to all physicians in training. A survey was conducted among all accredited U.S. residency programs in family medicine to examine training in geriatrics. The teaching sites most commonly used by the responding programs were the family practice center (used by 96.4 percent), nursing home (81.9 percent), family medicine inpatient ward (62.4 percent), and home care service (HCS) (48.2 percent). The professional most frequently in contact with the resident during training at an HCS was the attending physician. Longitudinal rotations (that is, long-term rotations involving part of each week for months or years) in geriatrics were used more often than block rotations. The HCS rotations ranked highest in residents' evaluations were those in which the resident followed patients long-term and discussed problems and management with a multidisciplinary team. A combined rotation involving a family practice center, a family medicine inpatient ward, and a home care service is discussed as an alternative method of teaching geriatrics in family medicine.     

《基础医学概论》教材编写的实践与探索

基础医学概论是针对医学院校非临床医学专业学生使用的一门贯通基础医学各学科、廓清基础医学整体脉络的综合性教材。以＂分子-细胞-器官-系统＂为主线,从＂正常-异常-康复＂方面重组、融合了基础医学10余门课程的内容,突破了传统按分科编写教材的思路,编写顺序独特,内容整体优化,使用对象明确,针对性强。     

地方性医学院校留学生教材使用现状及思考

留学生教材的选用是保证教育质量的首要环节。通过对比英文原版教材、国内出版教材及院校自编教材的优缺点,结合广西医科大学留学生教材使用现状和学生对教材质量评价的调查情况发现,学生对教材总体满意度较低、英文原版教材较国内出版教材及院校自编教材评价好等问题。最后,从把好教材选用关、加强师资队伍及教材建设、开设医学特色课程、建立有效的网络教学平台、重视学生的教学反馈意见等方面提出了建议。     

浙江省高校老年医学教育现状与对策思考

目的调查了解浙江省高校临床医学专业与护理学专业有关老年医学与护理课程的设置情况、继续医学教育项目,为老年医学教育和老年医护人才培养模式的构建提供依据。方法采用自行设计的调查问卷对浙江省14所设置临床医学专业和护理学专业的医学类院校进行书面或官网数据调查,同时取样浙江省继续医学教育网近4年老年医学类项目。结果在本科和专科教育阶段,仅有1所高校开设老年医学选修课程,5所院校开设老年护理课程;在硕士研究生教育阶段,有3所高校招收老年医学相关方向的硕士研究生,1所高校招收老年护理方向的硕士研究生,继续教育项目占比仅为3．4％。结论老年医学与护理教育现状堪忧,严重背离社会发展的需求,应当尽快增设老年医学与老年护理专业,建立老年医学与护理教育体系,完善老年医学人才培养模式。     

生理学系列教材建设的实践与启迪

本文介绍了贵阳中医学院生理学教研室结合教学改革的实践，开展生理学系列教材建设的情况。近10年来，教研室编写本科和专科生理学理论教材各1部，生理学普通实验教材、生理学综合性实验教材各1部，生理学习题集1部，共5部。此外，还参加了生理学全国规划教材编写共3部。本文就教研室开展生理学教材建设工作的意义和作用，以及如何正确认识和处理规划教材、协编教材、自编教材的关系等进行了探讨。     

核医学课程开展双语教学的探讨

为了探讨核医学课程如何开展双语教学并提高双语教学的质量,四川大学华西医院核医学科选用英文原版教材Textbook of Nuclear Medicine,采用中文和英文各半交错授课方式,课后对学生进行了问卷调查.调查结果表明,有60.0%的学生愿意接受双语教学;有95.0%的学生喜欢多媒体用英文、讲课用中文,且使用的教材英文和中文各占一半的方式;有67.8%的学生认为双语教学对其今后的发展有所帮助;有60.0%的学生能够听懂教师的讲课内容.实践证明,核医学开展双语教学是可行的,对学生今后的发展有所帮助.     

本科生物化学教材的比较与分析

从基本栏目、专题篇内容、与国外教材对比三方面回顾了六版本科生物化学教材，并对栏目设置、教材内容、学科分工和应用范围等进行分析，提出了进一步完善教材编写的一些建议。     

核医学课程开展双语教学的探讨

为了探讨核医学课程如何开展双语教学并提高双语教学的质量,四川大学华西医院核医学科选用英文原版教材Textbook of Nuclear Medicine,采用中文和英文各半交错授课方式,课后对学生进行了问卷调查.调查结果表明,有60.0%的学生愿意接受双语教学;有95.0%的学生喜欢多媒体用英文、讲课用中文,且使用的教材英文和中文各占一半的方式;有67.8%的学生认为双语教学对其今后的发展有所帮助;有60.0%的学生能够听懂教师的讲课内容.实践证明,核医学开展双语教学是可行的,对学生今后的发展有所帮助.     

Knowledge of aging and attitudes toward older people. A survey of Australian podiatric medical students

Podiatric medical students in Australia were surveyed to evaluate their reasons for entering podiatric medicine, knowledge of aging, attitudes toward older people, perceptions of treatment efficacy, and desire to specialize in geriatrics. Few students plan to specialize in geriatrics upon graduation (4%), with most preferring general practice (25%) or sports medicine (21%). However, knowledge of aging was good, and students had favorable attitudes toward older people and considered treatment of older people to be effective. Few age- or gender-related effects were observed. It is concluded that students' lack of desire to specialize in geriatrics may be due not to unfavorable perceptions of older people but rather to the low profile and limited development of geriatrics as a specialty area within the podiatric medical profession.     

End-of-life practices in European intensive care units: the Ethicus Study

Context  While the adoption of practice guidelines is standardizing many aspects of patient care, ethical dilemmas are occurring because of forgoing life-sustaining therapies in intensive care and are dealt with in diverse ways between different countries and cultures. Objectives  To determine the frequency and types of actual end-of-life practices in European intensive care units (ICUs) and to analyze the similarities and differences. Design and Setting  A prospective, observational study of European ICUs. Participants  Consecutive patients who died or had any limitation of therapy. Intervention  Prospectively defined end-of-life practices in 37 ICUs in 17 European countries were studied from January 1, 1999, to June 30, 2000. Main Outcome Measures  Comparison and analysis of the frequencies and patterns of end-of-life care by geographic regions and different patients and professionals. Results  Of 31 417 patients admitted to ICUs, 4248 patients (13.5%) died or had a limitation of life-sustaining therapy. Of these, 3086 patients (72.6%) had limitations of treatments (10% of admissions). Substantial intercountry variability was found in the limitations and the manner of dying: unsuccessful cardiopulmonary resuscitation in 20% (range, 5%-48%), brain death in 8% (range, 0%-15%), withholding therapy in 38% (range, 16%-70%), withdrawing therapy in 33% (range, 5%-69%), and active shortening of the dying process in 2% (range, 0%-19%). Shortening of the dying process was reported in 7 countries. Doses of opioids and benzodiazepines reported for shortening of the dying process were in the same range as those used for symptom relief in previous studies. Limitation of therapy vs continuation of life-sustaining therapy was associated with patient age, acute and chronic diagnoses, number of days in ICU, region, and religion (P<.001). Conclusion  The limiting of life-sustaining treatment in European ICUs is common and variable. Limitations were associated with patient age, diagnoses, ICU stay, and geographic and religious factors. Although shortening of the dying process is rare, clarity between withdrawing therapies and shortening of the dying process and between therapies intended to relieve pain and suffering and those intended to shorten the dying process may be lacking.      

医院信息系统教材现状分析与发展研究

从课程分类、应用领域两方面调研我国医院信息系统教材的基本情况,分析教材建设的特点与问题,介绍近年出版的典型教材,提出教材建设的发展方向,即具备基础性与前沿性、重视精品教材建设、全面采用现代信息技术。     

Advance directives: the views of health care professionals.

OBJECTIVES: This study examined the views and experiences of 20 physicians and 20 nurses at a major Canadian teaching hospital regarding the use of advance directives in clinical care. DESIGN: The participants were purposively drawn from four clinical specialties: family and community medicine, oncology, intensive care and geriatrics. Detailed interviews were conducted in person. Content analysis was used to code the data, which were further analysed with both quantitative and qualitative techniques. MAIN RESULTS: Thirty-nine of the 40 participants favoured the use of advance directives in clinical care; physicians had somewhat less positive attitudes than nurses toward such directives. Advance directives were thought by participants to be helpful in resolving disagreements between patients and their families about treatment options; in making patients more comfortable, both physically and psychologically, during the process of dying; and in opening up communication and trust among patients, their families and health care professionals. Concerns about the use of advance directives focused on the lack of clarity in some patients' instructions, the absence of legal status for directives, the possible interference with a practitioner's clinical judgement, the adequacy and appropriateness of patients' information about their circumstances, and the type of intervention (passive or active) requested by patients. CONCLUSIONS: New regulations and legislation are making the use of advance directives more widespread. Health care professionals should participate in the development and implementation of these directives. Continuing professional education is essential in this regard.