Introduction of ambulatory medical training in a Veterans Administration hospital.

Planners of postgraduate medical education in the United States have mandated that training programs include experience in continuing patient care in the ambulatory setting. Idiosyncratic administrative features and limitation of resources present relatively unique problems for the development of such programs in Veterans Administration teaching hospitals. The authors describe the implementation of a continuity of care clinic in a highly subspecialized large VA internal medicine training program. Crucially, all residents attend the clinic on the same day. The internal medicine educational program was altered to prevent conflict of the new clinic with other teaching activities. The program has been well received by the involved house staff members and has achieved some of the intended goals.     

Implementing university hospital ambulatory care evaluation.

The clinics of a single university hospital center were observed to determine a practical rationale for and impediments to implementing a medical care evaluation program. A quality assurance mechanism is especially important in the ambulatory care setting because of problems with patient compliance, lack of policy continuity, lack of intercommunication among care providers, no counterpart for most inpatient quality-oriented activities, structural defects in many clinics, and general emphasis on the inpatient medicine. Impediments to implementing quality assurance programs include the condition of clinic records and individual charts, lack of established criteria for care, problems of care provider intercommunication during the evaluation process, manpower availability, choice of evaluation method, and method of implementing resulting plans for corrective action.     

Ambulatory surgery and anaesthesia in HUKM, a teaching hospital in Malaysia: the first two years experience

Ambulatory or day care surgery is still in its infancy in this part of the world. Our newly built university affiliated hospital started its Day Surgery Centre in February 1998. It is the first multidisciplinary ambulatory surgery centre in a teaching hospital in the country. It caters for Orthopaedic surgery, Urology, Plastic surgery, Otorhinolaryngology, General surgery, Paediatric surgery and Ophthalmology. We have done 2,604 cases and our unanticipated admission rate is less than 2%. There has been no major morbidity or mortality. The problems of setting up a multidisciplinary ambulatory centre in a teaching hospital are discussed.     

An ambulatory medical education program for internal medicine residents

Teaching the fundamentals of ambulatory medicine has many well known difficulties. An education program with specific topics covered and modeled after continuing medical education programs for practicing physicians was instituted for residents in a university hospital clinic and was evaluated. The program was effective in improving the residents' knowledge, in enhancing their attitudes toward the clinic, and in improving their performance of influenza vaccinations. No adverse effects of the program were found. This approach, in which a curriculum is carefully defined and participation of the house staff is required, makes the ambulatory medical education process more accountable for what is taught.     

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.     

Experience with ambulatory anaesthesia in gynaecological patients

Ambulatory surgical care is becoming a common feature in Nigeria. Reports on the role of anaesthesia on outcome of surgery in ambulatory setting are rather scanty. In a 24-month period all patients who had gynaecological operations on ambulatory setting were identified and their hospital records reviewed. Sociodemographic characteristics, intraoperative variables, postoperative outcome and postoperative pain management were studied. A total of 28 patients had anaesthesia for various gynaecological procedures. All the patients were in the age range of 20-41 years and American Society of Anaesthesiologists physical status 1. Majority of the patients (71.4%) arrived for day care admission. General anaesthesia with relaxant technique of anaesthesia was the most commonly used technique of anaesthesia (75.0%). Late completion of surgery accounted for 70% (n = 7) of late discharges. Postdural puncture headache (PDPH) was the only adverse outcome seen in our study. Ambulatory anaesthesia is safe, efficient and promising for gynaecological day care procedures.     

The effect of independent practice association plans on use of pediatric ambulatory medical care in one group practice

We compared the use of pediatric ambulatory medical care of 640 children who switched from a traditional Blue Cross plan to more comprehensive independent practice association plans with that of matched patients who remained with Blue Cross in one large, suburban pediatric practice in Rochester, NY. A quasi-experimental, retrospective cohort design was used. Use of pediatric ambulatory medical care by patients in the independent practice association plan and control patients was determined by medical chart review for 1 year before and 1 year after each patient's switch. During the baseline year, patients who would join the independent practice association plan already had 19% more acute-illness visits than control patients. During the second year, patients in the independent practice association plan averaged 42% more acute-illness visits, 22% more well child-care visits, 93% more chronic-illness visits, 27% more after-hours visits, 53% more weekend visits, 185% more laboratory studies, and 70% more referrals. The shift toward independent practice association plans in this open-market setting increased use of ambulatory medical care for pediatric patients.     

Use of the hospital in a randomized trial of prepaid care

Health maintenance organizations (HMOs) achieve their cost savings through lower rates of hospital admissions. To determine whether HMOs selectively avoid discretionary hospitalizations, medical records were reviewed from a randomized trial where families were assigned to either HMO or free-for-service care. Physicians who were blinded to system reviewed 244 medical records and judged the appropriateness both of the hospital setting and of the medical indications for hospitalization. The rate of discretionary surgery was lower in the HMO, while the rate of nondiscretionary surgery was equivalent in the two systems. For medical admissions, rates of discretionary and nondiscretionary admissions were lower in the HMO. There were no observable adverse effects on health from the lower rates of nondiscretionary hospitalization, either because the net effect on health was small or because the HMO substituted appropriate ambulatory services. We conclude that HMO reductions in hospitalization rates do not occur "across the board"; discretionary surgery is selectively avoided.     

美国医学院教育的特点及对我国八年制医学教育的启示

美式医学教育是开办八年制医学教育的主要参考依据。充分学习借鉴美国医学教育的成功经验,对于我国八年制医学教育的发展、改革,具有重要意义。文章综述了美国医学院教育阶段的7个特点,扼要剖析了其对我国八年制医学教育的借鉴意义。     

医疗信息化人才培养方案探讨

分析医疗信息化人才建设现状及需求,从岗位设置、考核机制、继续教育体系、专项建设、人文关怀等方面阐述医疗信息化人才培养方案,为相关研究提供参考。     

The development of an education program in the pediatric emergency department.

The pediatric emergency department is a major educational resource in ambulatory pediatrics. A literature review indicates a lack of programs based on the identification of specific educational objectives in this setting. A model educational program for third-year pediatric clinical clerks and pediatric level I and II house officers is presented. Learning is defined in three areas: patient management, behavioral care needs, and hospital and community health care needs. Information on specific educational goals and objectives, learning experiences derived from them, and methods for evaluation of learning is provided.     

南京医科大学七年制临床医学专业人才培养效果评价

通过对毕业生及其培养或用人单位的问卷调查,本文分析了南京医科大学七年制临床医学专业人才培养的成效,以及江苏省医疗卫生事业发展对高层次医学人才的需求.结果 显示,临床实践能力和科研创新能力是医疗卫生事业发展所需要的高层次医学人才的重要能力;在三级甲等医院工作,具有硕士/博士学位、在专业技术岗位的被调查者更加看重医学生的科研创新能力;而在"1年通识教育、4年医学专业教育(含1年临床课程及见习、1年临床通科实习)、2年二级学科轮转"模式下培养的七年制临床医学专业毕业生的临床实践能力较强,但是科研创新能力不足,且学业负担偏重.因此,应当加强对七年制临床医学专业学生科研创新能力的培养和临床实践能力的通科训练.     

南京医科大学七年制临床医学专业人才培养效果评价

通过对毕业生及其培养或用人单位的问卷调查,本文分析了南京医科大学七年制临床医学专业人才培养的成效,以及江苏省医疗卫生事业发展对高层次医学人才的需求.结果 显示,临床实践能力和科研创新能力是医疗卫生事业发展所需要的高层次医学人才的重要能力;在三级甲等医院工作,具有硕士/博士学位、在专业技术岗位的被调查者更加看重医学生的科研创新能力;而在"1年通识教育、4年医学专业教育(含1年临床课程及见习、1年临床通科实习)、2年二级学科轮转"模式下培养的七年制临床医学专业毕业生的临床实践能力较强,但是科研创新能力不足,且学业负担偏重.因此,应当加强对七年制临床医学专业学生科研创新能力的培养和临床实践能力的通科训练.

Abstract：

An evaluation of 7-year medical education program in Nanjing Medical University was performed via questionnaire survey to the graduates and the staff of hospitals in which the graduates work,and the demand for advanced quality of medical graduates in the field of medical health care in Jiangsu Province is further analyzed. The results showed that the capacity for clinical practice and the capacity for research and innovation are the most important, which can meet the demands of health service development for high-level medical talents. The staff working in advanced hospitals, possessing master or doctor degree,or working as medical experts put more emphasis on the ability of the graduates to do innovative scientific research. Through the completed procedure of the 7-year program includes college general education for 1 year, medical education for 4 years ( containing senior clinical clerkship for 1 year and internship for 1 year) and alternation for medical and surgery subspecialties for 2 years, the graduates showed higher ability to do clinical practice, but not showed the growth of capacity for research and innovation. The most staff investigated proposed an enhancement in training for the capacity for innovative research and general clinical practice.     

Private physicians in ambulatory care training in U.S. medical schools

The contribution of private physicians to medical student education in ambulatory care was determined by a questionnaire directed to departments of family practice, internal medicine, and pediatrics in 124 U.S. medical schools and their branch campuses. The response rate was 84 percent. Of the responding departments, 82 percent offered an ambulatory care course in curricular years three and/or four, and 56 percent utilized private physicians in their courses. Departments of internal medicine were least likely to offer such a course, and their courses less frequently included teaching by private physicians (p less than 0.0001). When offered, internal medicine courses in ambulatory care were least likely to be required for graduation and involved the fewer students. Departments of family practice were most likely to offer ambulatory care courses and were most likely to utilize private physicians in their courses.     

台湾地区医学教育的特色及启示

台湾地区医学教育曾面临着与大陆医学教育相似的问题和困境。但通过改革,如设置灵活自主的弹性学制,制定客观细致的轮转指南,采取物尽其用的模拟教学,实施立足现实的医学人文教育,逐渐形成独特的体制和培养模式,对大陆医学教育改革有借鉴价值。     

军医大学八年制医学生普通外科实习模式改革探讨

八年一贯制的教学是目前培养高层次医学人才的重要方式,针对八年制普外科教学的特点,参考国内外主要医学院校的教学成果并结合军医大学学生的特点对八年制医学生普通外科实习模式改革进行探讨。     

A year-long clerkship in ambulatory care

Decreased availability of hospitalized patients for medical student education, a changing clinical environment in both hospital and outpatient settings, and the need for teaching the specific skills of primary ambulatory care mandate the development of outpatient-based clinical clerkships. A required third-year clerkship at Michigan State University College of Human Medicine combines a long-term structure and a defined curriculum with a wealth of clinical encounters. New approaches to the basic clinical education of medical students are needed to connect clinical resources, specialty expertise, and the special knowledge and skills needed for primary care. The clerkship described in the present paper represents a model for such clinical education.     

Graduate education in surgery in the Kingdom of Saudi Arabia. The challenge of growing pains

With the establishment of undergraduate medical education and the progress of health care in the country heralded by the return of well trained and dedicated physicians and surgeons, it was only natural that the attention will be focused on establishing graduate training for the different medical specialties in the Kingdom of Saudi Arabia. This paper addresses the current status of general surgery training in the country and compares our model with the experience of others from the perspective of a program director. It is not the exception, but it is the rule to have challenges at this stage of development. The problems are multifactorial and need to be addressed by all those concerned with an open mind. I pretend no special farsightedness and my authority rests only on genuine concern about the issues and experience from being both a surgeon and a program director. The aim is of course to produce a future generation of well trained surgeons able to meet the challenge and take the lead in the medical care of this country. Once sound general surgery training is in place, training in specialty surgery such as thoracic and cardiac to name a few will follow suit.     

八年制医学生外科学临床见习教学体会

临床见习是医学生由理论学习向临床实践的重要转折。八年制医学生是一种新的培养方式,目标是毕业时达到临床医学博士研究生水平。结合八年制医学生自身特点及培养目标,外科学临床见习由各三级学科主治医师或以上职称医师带教,使用多种教学方式加强品德和伦理学教育、重视三基训练和临床思维的培养、灌输循证医学观念和科研意识、促进医学英语学习,取得了较好的学习效果。