Mental health education in three primary care specialties

The authors used a questionnaire to examine the characteristics of the mental health components of residency training in traditional internal medicine, primary care internal medicine, and family practice. Traditional internal medicine programs relied almost exclusively on the consultation method and inpatient facilities, offered little formal instruction, used the psychiatrist as the primary teacher, and spent considerably less per resident for mental health training than the other programs. Psychologists and social workers as a group were the primary mental health teachers in family medicine residencies. Traditional internal medicine programs emphasized psychophysiological reactions and simple pharmacotherapy, while primary care internal medicine and family practice programs concentrated on life cycle issues, psychosocial awareness, and simple psychosocial management techniques. None of the three types of residencies focused on complex psychiatric disorders or management techniques. The three specialties differed significantly (F = 13, p = .0001) in the total amount of time on average the resident spent in formal mental health instruction. The need for evaluation of the outcome of training is also discussed.     

Teaching nursing homes revisited. Survey of affiliations between American medical schools and long-term-care facilities

A survey of American medical schools was conducted to examine the growth of teaching nursing home programs. Ninety percent (109/121) of schools surveyed reported affiliations with a nursing home(s) for teaching, research, and/or clinical care. Most affiliations occurred in the last six years and were typically with two or more nursing homes. They were usually 120 beds or more in size, and the majority were nonprofit or Veterans Administration units. Eighty-three percent (101/121) of medical schools had teaching programs involving nursing homes. Medical school courses that utilized nursing homes as teaching sites were largely selective or elective and were offered primarily in the senior year. Training programs involving residents were usually mandatory and mainly involved the departments of internal medicine and family practice. Fifty-five percent (66/121) of the schools had research programs involving nursing homes.     

Residency training in internal medicine: program design in an era of constraint.

Directors of postgraduate internal medicine programs face many problems in program design, particularly when numbers of house staff continue to decrease. This paper examines the training requirements of a resident in internal medicine and proposes a curriculum based on set rotations in the three key areas of training--subspecialty services, critical care and the clinical teaching unit. The distribution of time in these three areas and the balance of exposure to inpatients and outpatients are discussed in detail. This program design ensures exposure to all the key elements of internal medicine in 3 years and should prevent significant gaps in knowledge at the time of certification. The implications for "service" in major teaching hospitals is discussed. Hospital departments and administrators must confront the prospect of hospital units without house staff. Most important, program directors must resist sacrificing the pedagogic essentials of a training program for service requirements.     

The characteristics of training in ambulatory medicine in U.S. residencies

To determine the characteristics of training in ambulatory internal medicine, all internal medicine residency programs in the United States were surveyed in 1981-82. Thirty-eight percent of 477 hospitals responded. Quantitative information was sought regarding the specific features of the ambulatory residency programs, formal teaching conferences, supervision of residents, and evaluation of residents in ambulatory care. According to the responses, the training of the small cadre of primary care residents does emphasize ambulatory medical experience, supervised by an increasing number of faculty members in general medicine. Formal post-clinic conferences, analogous to inpatient attending rounds, are held substantially more often in hospitals with primary care programs than in hospitals without primary care programs. Formal ambulatory teaching conferences stress both traditional topics important in internal medicine and psychosocial issues. However, the authors could detect little effect of these activities in primary care programs on the training of traditional internal medicine residents even within the same hospital.     

Reducing ward-clinic conflicts by rotational scheduling of house staff.

Many internal medicine residency training programs are being modified to permit each resident to gain more outpatient experience, including providing continuous care to a defined panel of patients for three years. Increasing emphasis on these outpatient responsibilities and education, however, places demands on the resident that conflict with his responsibilities on the inpatient wards. In this paper the authors describe the development and implementation of a rotational scheduling system aimed at substantially alleviating the conflict between inpatient and outpatient responsibilities. During the first year of operation 84 percent of house staff members indicated their preference for continuing the system in future years.     

A third-year family medicine clerkship based in an academic family practice center

In this paper, the authors describe the planning, curriculum, and evaluation of a five-week family medicine clinical clerkship for third-year students based in an academic family practice center. The program is an outpatient experience utilizing several innovative techniques: (a) problem-based learning that focuses on patient management tutorials, (b) consultation sessions with individuals offering specialized expertise, (c) supervised patient care in a family practice center and with a nursing home inpatient teaching service, and (d) workshops on various topics, such as office-surgical techniques, practice management, and alternative methods of health care. Evaluation of the course has demonstrated the merits of careful planning with student input, the need for flexibility, and the value of focusing on concepts in ambulatory care.     

Inpatient performance of primary care residents: impact of reduction in time on the ward.

The inpatient (ward/intensive-care-unit) performance of primary care medical residents was compared with that of their peers in the standard internal medicine residency program. The primary care residents spent half as much time on inpatient rotations as did their peers in the first two years of training. History-taking, physical examination, case presentation, record-keeping, patient management, and overall performance were assessed and scored by the attending physicians using the American Board of Internal Medicine's Clinical Performance Evaluation Form. The performances of the two groups were nearly identical, suggesting that substantial time in the first two years of residency can be devoted to ambulatory training without markedly compromising development of acute care skills.     

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。     

The impact of a new geriatric program in a hospital for the chronically ill.

Reports of the rapidly increasing proportion of persons aged 65 years and more in Canada and the resultant need for changes in the country's health care system prompted experimental changes in the operation and training procedures at St. Mary's of the Lake Hospital, Kingston, Ont. Aimed at better patient care and at better education of medical house staff in geriatrics and long-term care, the revised program is permeated with the philosophy of rehabilitation. It includes full-time staff, a geriatric outpatient clinic, a day hospital, a team approach to patient care (with regular team audits), problem-oriented medical records, a formal physical medicine section with a district inpatient unit, and an intensive inservice education program. After the first year of the program patient outcome had improved and more efficient use was being made of continuing care beds because of larger numbers of patinets being discharged home after shorter stays. This may be one avenue for deceleration of our country's dismal rate of institutionalization.     

提升老年科临床实习学生整体医学素质的探讨

通过增进老年科临床实习学生与患者的情感交流,训练其用整体思维对待老年人多系统疾病并存情形,培养其从多角度对老年患者进行整体健康水平评估和管理,以及通过日常临床带教和教学查房不断提高其医患沟通技巧等。对老年科临床实习学生进行医学人文精神、整体医学、健康管理、医患沟通等重要医学理念的培养,提升其整体医学素质,从而全面提高其工作能力,使其树立良好的医德医风,尽快适应临床工作。     

Ambulatory care training during core internal medicine residency training: the Canadian experience.

OBJECTIVE: To determine the status of ambulatory care training of core internal medicine residents in Canada. DESIGN: Mail survey. PARTICIPANTS: All 16 program directors of internal medicine residency training programs in Canada. OUTCOME MEASURES: The nature and amount of ambulatory care training experienced by residents, information about the faculty tutors, and the sources and types of patients seen by the residents. As well, the program directors were asked for their opinions on the ideal ambulatory care program and the kinds of teaching skills required of tutors. RESULTS: All of the directors responded. Fifteen stated that the ambulatory care program is mandatory, and the other stated that it is an elective. Block rotations are more common than continuity-of-care assignments. In 12 of the programs 10% or less of the overall training time is spent in ambulatory care. In 11 the faculty tutors comprise a mixture of generalists and subspecialists. The tutors simultaneously care for patients and teach residents in the ambulatory care setting in 14 of the schools. Most are paid through fee-for-service billing. The respondents felt that the ideal program should contain a mix of general and subspecialty ambulatory care training. There was no consensus on whether it should be a block or continuity-of-care experience, but the directors felt that consultation and communication skills should be emphasized regardless of which type of experience prevails. CONCLUSIONS: Although there is a widespread commitment to provide core internal medicine residents with experience in ambulatory care, there is little uniformity in how this is achieved in Canadian training programs.     

A family practice residency network. Affiliated programs in the Pacific Northwest

The Department of Family Medicine at the University of Washington School of Medicine has developed a regional network of affiliated family practice residency programs in the Pacific Northwest. Collaborative efforts among the seven participating programs are directed to common needs such as curriculum development, sharing of educational resources, program evaluation, problem-solving of operational programs, and coordination of resident rotations. This family practice residency network is a logical and necessary extension of the program that has been developed in Washington, Alaska, Montana, and Idaho for teaching medical students. Regional undergraduate and graduate teaching programs in family practice represent an important role for the university relating to its surrounding region through the collaborative efforts of the medical school and participating hospitals and physicians in the community.     

Public policy and the supply of primary care physicians

The decline in general practice, the arrested growth of family medicine training programs, and the increased subspecialization of internal medicine and pediatrics are responsible for the continuing decrease in the proportion of physicians in the United States who practice a primary care specialty. Since 1963, the number of physicians has more than doubled, but the ratio of office-based primary care physicians to the national population has decreased. This trend has been especially pronounced in rural areas and impoverished urban communities. There is evidence that the proportion of young physicians entering primary care specialties is declining. Medical education has become increasingly reliant on service income, making it difficult to fund training in primary care specialties. Grants for graduate training in primary care specialties have not increased with inflation, and outright elimination of these programs is under consideration. Public programs that fund medical education must be reformed to improve the geographic and specialty distribution of physicians.     

The effect of outpatient visit volume on inpatient teaching services

Ambulatory clinics at public teaching institutions often have less potential for generating revenues than the inpatient services. In times of fiscal constraint, they are, therefore, vulnerable targets for cutbacks in services. A financial crisis in the Bexar County Hospital District led to administrative changes which caused a 20 percent decline in outpatient visits for the entire year. This resulted in a 10 percent fall in the inpatient census and adverse effects on teaching programs and on hospital finances. A regression of inpatient activity with outpatient activity showed a highly significant correlation (r = .57, p less than .01). The decline in the inpatient census contributed to a renewed institutional commitment to ambulatory services. In addition to their direct role in patient care and training, the outpatient clinics thus appear to be essential to the success of inpatient teaching programs. These data emphasize the importance of "vertical integration" (that is, ownership of facilities providing several levels of care) of services to the survival of academic health centers.     

多元化教学法在优质护理病房护生带教中的应用探讨

目的 探讨多元化教学法在优质护理病房中应用的效果。方法 在优质护理病房应用多元化教学法,包括构建愉快的人文氛围,实习导师制带教、注重多种能力的培养、阶段教学法、改革出科考核,并采用自行设计的问卷调查护生对该教学方法的评价。结果 护生对在优质护理病房应用多元化教学法表示满意。结论 在优质护理病房应用多元化教学法能够稳定护生的专业思想,帮助护生了解优质护理内涵,调动学习积极性,提高护生的基础护理、健康教育、理论联系实际、表达与沟通等多方面的能力,提高了优质护理服务示范工程的质量。     

PBL教学法在老年病学住院医师教学查房中的应用

教学查房是临床教学中的重要组成部分,某院老年病科在住院医师教学查房中引入以问题为基础的学习（PBL）方法,即以问题为基础,以住院医师为中心的教学模式,带教教师根据教学大纲收集典型病例,提出并设计问题,配置学习小组,引导住院医师查找相关资料,正确的运用临床思维,以提问和相互提问、组内和组间讨论等形式,寻找解决问题的方法,最后总结该病例的诊治经过,设计合理的治疗方案。在教学查房的过程中运用PBL教学法,激发了住院医师对老年病学的兴趣,同时调动了住院医师的学习主动性,培养了其独立思考和高层次临床思维能力,同时进一步提高了带教教师综合素质。     

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。     

全科医学培训需求分析

目的了解2000-2006年全科医学规范化培训学员的教育需求变化。方法采用自行设计的调查问卷调查2006年在我院参加上海市全科医师规范化培养的62名学员对全科医学规范化培养的认识及需求,并与2000年培训的53名学员的调查结果相比较。结果2000年培训的学员中,36％（19／53）认识全科医学（“六位一体”内容）、94％（51／53）愿意接受全科医学培训、57％（30／53）对社区工作不满意;2006年培训的学员对全科医学的认识、对培训的接受程度及对工作环境的满意程度均有提高,分别为100％（62／62）、100％（62／62）和98％（61／62）,但单位领导不重视仍是对社区工作不满意的主要原因。结论目前社区全科医生对全科医学教育需求有了很大提高,在有些方面还有待政策支持。     

全科医师规范化培训的探索与实践

作为卫生部全科医师规范化培训试点基地,笔者通过多途径开展临床师资培训,如全科医学与社区卫生服务短期师资培训、院报宣传全科医学临床带教知识、全科医学教研室活动、社区卫生服务中心全科诊疗等,提高了临床师资的带教水平;通过改进临床培训方案及加强人文素质培养,如增加常见病的培训病例数、添加对肿瘤科和老年病科实践的具体要求,以及让学员参与党、团、工会组织的学习与活动、参与业务管理部门组织的医疗社会活动、参观人文景点、聆听知名医学专家的人文社会学讲座等,提高了全科医师规范化培训质量,对广泛开展全科医师规范化培训具有一定的借鉴意义。     

The teaching of liberal arts in internal medicine residency training

Forty-four members of the Association of Program Directors in Internal Medicine and 58 members of the Society for Research and Education in Primary Care Internal Medicine completed questionnaires on the teaching of liberal arts in internal medicine residency programs and the importance of liberal arts to the practice of medicine. They rated economics of medical care and bioethics as essential to residency training. Law and organization of the health care system as well as economics and bioethics were rated as essential to medical practice. Although there was great variability in the curricula represented, over 40 percent of the respondents reported having formal lecture and/or seminar exposure to these topics in their programs. Problems encountered in implementing liberal arts programs included lack of curriculum time, limited-faculty members, and a lack of interest on the part of residents. There is a need both to arrive at a consensus among residency directors and to explore means of developing interdisciplinary faculties if the liberal arts are to form an established part of internal medicine residency training.