国外农村基层医师医学培养项目实施现状、成效及评价的系统综述

背景　2010年我国农村订单定向医学生免费培养工作启动，旨在为农村地区培养具备本科学历的全科医生，缓解农村地区基层医师匮乏的现状。本研究通过系统综述了解国外类似项目的实施现状、成效及评价，为我国农村订单定向医学生培养工作评价和改善提供理论参考。目的　了解国外农村基层医师医学培养项目实施现状、成效及评价指标方法等。方法　2019年2-7月，采用系统综述的方法，以“医学教育”“医学教育+医学本科生”“医学院校教育”“医学生”“住院医师规范化培训”“医学专业+人力资源”“农村地区”“农村基层医疗服务”“医师执业地点”“农村基层医师”“农村基层医师培养”“农村医学实习”“农村临床见习”为检索词，检索Ovid MEDLINE、PubMed、Cochrane及Google Scholar主要英文数据库，获取2000-01-01至2019-01-01发表的关于全球农村基层医师院校教育及住院医师培训等项目的实施现状、成效及评价的英文文献。结果　最终纳入53篇文献，分别来自美国、加拿大、澳大利亚、日本、泰国及南非6个国家，包括20个院校教育项目和6个住院医师培训项目。文献显示各国农村基层医师培养项目均具有指向性招生策略、面向农村卫生和全科医学的临床课程体系、以农村执业的家庭医生为临床导师及农村地区临床实践基地等要素；培养项目学生选择家庭医学为执业专业、农村地区执业率和长期农村保留率均明显高于非培养项目学生，两者国家医疗执照考试成绩和通过率无明显差异。长期农村地区临床实践培训、招生策略倾斜农村成长背景学生及农村执业的家庭医生导师是影响项目最终效果的关键因素。结论　医学教育是解决农村基层医师匮乏的有效途径。国外农村基层医师培养项目的招生策略、临床课程体系设置、导师指导及评价可为我国农村订单定向医学生培养工作提供有益参考。     

Career choice of 'fifth pathway' graduates from New York state medical schools

Graduates of "fifth pathway" programs at medical schools in New York state between 1976 and 1978 were studied to determine their professional careers and choice of medical specialties. Of the 545 physicians participating in the program, 510 were able to be located. Of this latter cohort, 177 (34.7 percent) had entered primary care fields as of 1981. Of the physicians no longer in residency training, 19.1 percent had full-time salaried positions in academic institutions, and the remaining physicians were engaged in various clinical medical activities. Of the 545 fifth pathway graduates, 74 (13.6 percent) had not been able to pass the licensing examinations as of 1981, and an additional 54 (9.9 percent) had not taken those examinations. Comparisons with regular students graduating from a medical school in New York state showed that fifth pathway graduates were more likely to select nonprimary care specialties than primary care specialties (p less than 0.001). These data suggest that although a majority of graduates of fifth pathway programs in New York state are involved in the provision of health care, a small number are still unable to engage in the practice of medicine.     

Analysis of a medical internship.

Considerable discussion concerning the fate of the internship within the postgraduate period of physicians' training has taken place. Some specialty boards have eliminated the requirement of a free-standing internship. However, no replicable study findings defining exactly what an intern does have been reported in the literature. By analyzing the patient experiences that a straight medical intern encountered, the authors of this paper illustrate what many persons have previously said: the traditional internship is unrealistic with respect to the practice of medicine. The intern described here assumed care for acutely ill persons to the exclusion of all other responsibilities. The importance of objective and reproducible record-keeping is emphasized for both established and newly created programs in the primary care specialties.     

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.     

The Canadian general internist: education and future role

Available manpower data indicate that for the forseeable future there will be a continuing requirement in Canada for specialists in general internal medicine. While these specialists will be located predominantly in community hospitals, they will also be needed in university medical centres. The major roles of the general internist will be (a) to provide consultative service to primary care physicians and to other specialists, (b) to provide continuing care to patients with complex serious illness and (c) to participate in intensive care, particularly in community hospitals. Therefore training programs in this specialty must provide adequate experience in consultative medicine in both university and community hospitals, an opportunity to follow up patients with chronic serious illness over long periods, and experience in a variety of intensive care settings including surgical intensive care units. In some university departments the organization and supervision of training programs in this discipline have been carried out by a division of internal medicine that has equal status with other specialty divisions within the department. This seems to have been a salutory development.     

Competencies required for the practice of geriatric medicine as a consultant physician.

Geriatric medicine in Canada is now being viewed not merely as an academic specialty but, rather, more broadly as a service specialty providing consulting support to other physicians. Any redesigning of training programs will have to be done with this fact in mind. We drew up a list of competencies required for consultant practice in the field and presented them to other practitioners of geriatric medicine and members of the Canadian Society of Geriatric Medicine for feedback. We believe that the resulting list of competencies can be used as a starting point for redesigning training programs in geriatric medicine.     

德国全科医生培养体系对我国社区全科医生临床教育的启示

德国家庭医生以诊所经营为主,实行自我管理,提供基本医疗服务;德国医生自由执业的基础是德国的同质化医学教育;医学教育改革强调理论和实践教学贯穿医学教育全过程;毕业后教育按照全科医学专科特点设置轮转方案和考核标准,强调在诊所的临床实践时间并注重心身医学的教育;通过医疗保险的给付制度督促医生的继续教育。本文借鉴德国全科医生培养模式,提出加强本科院校教育期间的全科医学教育启蒙,并在加强全科医生的临床实践环节、全科医学培训基地建设以及社区带教师资能力提升等方面提出建议,以期对我国的全科医生培养提供参考。     

Two combined residency programs in internal medicine and pediatrics

Combined residency training in internal medicine and pediatrics is becoming a popular postgraduate program among graduating medical students. The number of such programs has increased rapidly but with little interchange of ideas and without the benefit of a national data base. In this paper, the authors review the experience of two combined programs. Initially established because of the desire to provide broad-based training in primary care, the programs now offer a curriculum that prepares residents for primary care or education in the subspecialties. The difficulty for residents of achieving competence in two disciplines is compounded by a lack of faculty role models. The two programs offer special advantages to the residents and the departments involved. The career outcomes of program graduates have varied from primary care or subspecialty practice in one or both disciplines to faculty positions in teaching institutions. Whether the program remains successful will depend on the ability of its graduates to offer special talents to academic and clinical practice settings and on the availability of funding.     

The stability of early specialty preferences among US medical school graduates in 1983

Medical graduates in 1983 were in preclinical training when the Graduate Medical Education National Advisory Committee forecast a surplus of 70,000 physicians by 1990. Among the problems identified was the nuclear role of medical schools in affecting specialty choices. To understand this role further, the current study determined the stability and evolution of specialty preferences between the time of the Medical College Admission Test and the senior year of medical school. The study included 10,321 US medical school graduates in 1983. Eighty percent changed their specialty preference during this interval, demonstrating the substantial effects that medical schools have on specialty selection. The stability of early preferences ranged from 41% to 1%. Interest in primary care specialties declined among both men and women; interest in specialty care and supporting services increased during this five-year longitudinal study. These findings parallel shifts away from primary care among US medical school graduates in 1978 and 1983.     

Migration of physicians from one specialty to another. A longitudinal study of US medical school graduates

To demonstrate the extent to which physicians change their specialty, randomized samples of the graduating classes of 1960, 1964, and 1968 were studied with respect to their self-designated specialties in 1971 and 1976. Of the 2,046 physicians in the three samples, 333 (16%) changed their specialty between 1971 and 1976. It was 8% for the 1960 cohort, 11% for 1964, and 29% for 1968. Of all the changes, 78% were from one specialty practice to another or back to a formal residency in a different specialty; 22% changed from one specialty residency to either practice or another residency in a different specialty. Between 1971 and 1976, a total of 127 (16%) of 783 primary care physicians changed their specialty. The magnitude of this change must be considered in planning for distribution of physicians by specialty.     

开展临床预防医学教育的实践与体会

目的对近年来本院开展的临床预防教育实践经验进行总结，探讨临床预防教育的模式。方法结合临床医学专业的特点，采用课程教育、选修课、入学教育及课外科技活动等多种形式，对临床医学专业、全科医学专业及其它医学专业学生开展临床预防观念的灌输和基本理论、服务技能的教育实践。结果我院在临床预防教育方面积累了一定的经验，但在课程设置、实践教学环节及师资等方面还需要进一步加强与改善。结论临床预防教育是医学教育的重要组成部分，逐渐成为当今医学发展一大趋势。     

Quality of care in family practice: does residency training make a difference?

As the proportion of physicians who enter residency training in family practice steadily increases, so does the need to evaluate the impact of their training and postgraduate education on the quality of care in their practices. We audited the practices of 120 randomly selected family physicians in Ontario, who were separated into four groups: nonmembers of the College of Family Physicians of Canada (CFPC), members of the CFPC with no certification in family medicine, certificated members without residency training in family medicine and certificated members with residency training in family medicine. The practices were assessed according to predetermined criteria for charting, procedures in periodic health examination, quality of medical care and use of indicator drugs. Generally the scores were significantly higher for CFPC members with residency training in family medicine than for those in the other groups, nonmembers having the lowest scores. Patient questionnaires indicated no difference in satisfaction with specific aspects of care between the four groups. Self-selection into residency training and CFPC membership may account for some of the results; nevertheless, the findings support the contention that residency training in family medicine should be mandatory for family physicians.     

Compliance with screening mammography. Survey of primary care physicians

A survey of primary care physicians in the greater Tampa Bay metropolitan area was conducted to determine compliance with screening mammography and associated physician characteristics. Information requested included their age, sex, specialty, and board certification status, and the ages and frequencies that they recommend screening mammography for their patients. A total of 565 physicians responded. Even though 88% indicated they follow American Cancer Society recommendations when advising screening mammography, only 62% were actually in full compliance. A significantly greater percentage of obstetricians/gynecologists were compliant (74%) compared to other specialties (family practice, 57%, p = .006; internal medicine, 56%, p = .007; general practice, 53%, p = .003). Women physicians were more likely to be compliant than men (83% versus 58%, p less than .001), and younger physicians more likely than older physicians (72% versus 49%, p less than .001). There was no significant difference in compliance rates between board certified and noncertified physicians.     

The crisis in primary care and the role of medical schools. Defining the issues.

While a number of issues have diminished the attractiveness of primary care residency programs to USGs, the absolute number of residents in these programs has increased rather than diminished over the past decade, although the proportion of USGs choosing these fields has decreased. In the current arena of medical practice, there are many reasons why these fields are not among the most attractive, and there are several remedies that could be applied to increase their attractiveness. Focusing on medical schools as the sole cause of this dilemma, however, is the least effective way of accomplishing this objective; in addition, this will allow those truly able to increase interest in these fields, such as state and federal governments, to have a reason for not doing so. As long as the medical marketplace is sufficiently large enough to accommodate more than the number of graduates from US medical schools in "desirable" residency training positions, one can never effectively "force" a choice of residency training, nor should one. Primary care can be among the most rewarding of specialties, if adequately supported. It is this support that is lacking and must be addressed.     

A survey of postgraduate training for family practice

The results of a survey of Canadian primary care physicians for the Canadian Medical Association (CMA's) Task Force on Education for the Provision of Primary Care Services are reported. Recent Canadian medical school graduates in primary care practice reported that the three major training routes (rotating and mixed internships and family medicine residencies) each prepared them differently for practice. The graduates of 2-year family medicine residencies were more satisfied with their preparation than were the graduates of the other major training routes. A 2- or 3-year family medicine residency was preferred by 50% of the respondents, although only 33% of them had actually taken one of these routes. There was considerable agreement in the respondents' assessments of the types of postgraduate education needed for primary care practice. The results of this survey were consistent with the recommendations in the final report of the CMA's task force.     

Family physicians' perceptions of health manpower needs in West Virginia.

West Virginia family physicians feel that they are able to assess the health care needs of their communities. There is a need for more physicians in all of the major specialties in West Virginia, but the largest numbers of physicians are needed in family practice and obstetrics. More registered nurses and licensed practical nurses are needed than any other health care professionals. Twenty-five percent of the respondents are actively recruiting associates, and 48 percent have seriously considered leaving, or are leaving West Virginia. The most commonly cited reasons for leaving are inadequate reimbursement, the state's economy, SB-576, lack of tort reform, and state government in general. The greatest advantage given to practicing in the state are its people, the quality of life, and home and family. In addition, the greatest problems are reimbursement, state government, the malpractice climate and the state economy. The survey shows that state government needs to show a good faith effort to enact tort reform to improve relations with physicians. The threat of losing more physicians is real and must be addressed. Improving the climate for the practice of medicine is a viable solution to West Virginia's manpower problems. There is also a need to continue all present health care professional training programs. More emphasis should be placed on recruitment and retention of nursing students. There is expressed support for nurse midwives, nurse practitioners, and physicians' assistants all working under the supervision of physicians. The finding that home and family are frequently listed as advantages to practicing here indicates recruitment and nurturing of students from underserved areas should be increased.(ABSTRACT TRUNCATED AT 250 WORDS)     

Deficiencies in the education of musculoskeletal medicine in Ireland

Background  Basic competency in musculoskeletal medicine is essential for many specialties being particularly relevant to primary care. Aim  The purpose of this study was to objectively assess the adequacy of musculoskeletal education at multiple levels of medical training from undergraduate level to primary care. Methods  A previously validated musculoskeletal examination was administered to 303 volunteers consisting of medical students, orthopaedic specialist registrars, general practice trainees and general practitioners. Results  Forty (71%) general practitioners and 74 (71.8%) general practice trainees failed to obtain the passing score of 70. Sixty-three (87.5%) medical students who had completed an intensive 1-week long course in musculoskeletal medicine failed the examination. The pass rate improved significantly for general practitioners who had completed a postgraduate rotation in musculoskeletal medicine (47.8 vs 18.1%, P < 0.01). Conclusions  These findings suggest that training in musculoskeletal medicine is inadequate at multiple levels of medical education with reform urgently required.     

Physician supply and distribution in Georgia

Physician supply in Georgia must be considered an urgent issue. Several important points must be recognized and addressed. The lowest physicians rates are in the more rural county population groupings. The only county population grouping with a surplus of physicians is in the over 150,000 population. The majority of physicians are concentrated in the metropolitan counties. Sixteen percent of all physicians practice in the 134 counties having less than 50,000 population. The majority of physicians are in primary care specialties. Family practice is the most dominant specialty in rural areas. By the year 2000, Georgia can expect to add 5,600 physicians due to growth. By the year 2000, Georgia can expect to lose 2,600 physicians due to retirement. Family practitioners are the most uniformly distributed of the specialties examined. They are also the specialty most needed. The average age of Georgia physicians is 46. General surgeons are in the oldest average age group (50), whereas internists are in the youngest (44). Older physicians are concentrated in the more rural areas. A significant number of all physicians are over age 55. The majority of these will be retired by the year 2000. Physicians over age 65 represent 9.2% of all physicians from the survey. In Georgia, 13.6% of all physicians were Foreign Medical School Graduates. They tend to locate their practices in medically underserved areas. The specialty choices most frequently favored by FMGs are: pediatrics, internal medicine, family practice, and obstetrics/gynecology. A total of 71.2% of all physicians accept Medicare patients; 83.8% accept Medicare patients. Ninety-two percent of all obstetricians accept obstetric patients, but this participation is threatened by problems with malpractice insurance.     

Critical care medicine in China: history and perspective

Critical care medicine began in 1982 in China and is still in a phase of rapid development.Despite the inadequate resources compared with those of developed countries,critical care medicine has been recognized as a specialty by the government and by other specialties.National critical care societies are dedicated to promoting professional education and the academic improvement of critical care medicine in China.Although critical care services and clinical research are still underdeveloped due to scarce resources,great improvement is expected in the near future.