The structure of memorized knowledge in students and clinicians: an explanation for diagnostic expertise

This paper provides for the first time evidence of a consistent difference in the memory structures of novice and expert clinicians. The diagnostic performance of first- and third-year clinical medical students, senior house officers, registrars and consultants on four clinical problems in general medicine was studied. Comparisons were made of all diagnostic interpretations offered and the forceful features (personally important pieces of information which act as a key to particular memory structures which in turn give rise to the clinical interpretation) from which these were derived. Results demonstrate that the numbers of interpretations made and the numbers of forceful features identified did not differ significantly between groups (P greater than 0.05). However, the actual interpretations made in three out of four cases, and the actual forceful features identified in all cases, did differ significantly between groups (P less than 0.05). The numbers of interpretations made by all groups were large and demonstrated enormous variability. Highly individualized multiple responses to clinical information are associated with easy diagnoses. We conclude that there is no difference between groups of differing clinical experience in the breadth of thought but that there are marked differences in the precise content and structure of thought. This allows coherent explanation of variation in diagnostic expertise with clinical experience. The significance of the findings is discussed.     

高等医学院校医学化学教材改革的几点思考

医学的发展已进入分子水平，医学生必须具有扎实的化学基础才能适应专业学习及临床、科研工作的需要。现行医学化学教材大多沿用几十年前的模式，部分内容陈旧滞后，实用性不强。面对现实，改革势在必行。我们认为，突出重点、注重实用、体现医学特色应作为改革的方向。     

Development and implementation of an innovative intern training programme

The quality of medical education during internship is a cause for concern. This paper describes a structured educational programme for interns that was based around learning modules, clinical attachments and bedside teaching. The programme was incorporated into the term rotation of interns within an Area Health Service, and evaluated. Learning modules were timetabled by a Programme Coordinator and interns were reminded to attend. Clinical attachments were organized by the interns from a list of willing supervisors. Attendance at timetabled learning modules averaged 67%, which was greater than the 27% attendance at clinical attachments. Both sessions received high ratings for quality and clinical relevance. This structured education programme was based upon adult learning methods and was both feasible and well received by interns. Intern training programmes need to be programmed into the working week to ensure attendance, and modified following evaluation by interns. Such programmes should be considered by all hospitals to which interns are allocated.     

Eligible Veterans'' Choice Between VA-covered and Non-VA-covered Dental Care

Veterans who were eligible for dental care in Department of Veterans Affairs (VA) facilities at no monetary cost responded to a mailed questionnaire. Seventy-one percent were aware that they were actually eligible for VA dental care. However, only 48 percent reported the VA as their only or primary source of dental care. Eligibility status, perceived quality of VA dental care, use of VA medical care, perception that one's income meets expenses, and perceived need for dental care were significant correlates of using the VA as one's current source of dental care. Level of formal education, perception that one's income meets expenses, transportation pattern, geographic distance from a VA facility, and eligibility status were significant correlates of using the VA as one's current medical care source. Research on VA utilization offers the opportunity to study issues of access to, and use of, a large public health care system whose patients largely receive care at no monetary cost. Veterans' use of VA dental and medical care is apparently influenced by a wide variety of factors, ranging from barriers to access to non-VA systems, to characteristics of the VA delivery system itself, to need for treatment.     

浅谈如何提高医疗质量

为提高医疗质量，论述以下三点：①强调“以病人为中心”，坚持服务方向、整合优化流程、收集反馈信息；②加强医务人员思想道道修养，在加大教育、监督、管理力度三个方面下功夫；③强化引导管理模式，采取开展质量分析、狠抓环节质控、进行法律法规引导等方法收到较好效果。     

米利酮对豚鼠心乳头肌及主动脉条的作用

米利酮是非洋地黄，非儿茶酚胺类强心药，具有明显的正性肌力和扩血管作用。国外用于治疗难治性心衰及洋地黄中毒的心衰病人。本文用豚鼠乳头肌及主动脉条进行实验，结果表明合成与进口米利酮的正性肌力作用效价相同，对抗去甲肾上腺素缩血管的作用也等同。     

福田4500型B超软故障检修与分析

通过福田4500型B超软故障检修与分析，介绍了该机故障检修分析过程及造成该故障的原因。     

Teaching medical students about the appropriateness of social and sexual contact between doctors and their patients: evaluation of a programme

The purpose of this study was to assess the impact of an educational intervention on medical students' attitudes toward social and sexual contact with patients by doctors from three medical specialties (general practice, obstetrics/gynaecology and psychiatry). Medical students from two consecutive fifth year classes at one medical school participated in one 3 hour session that included instruction on the standards of the profession that prohibit doctor–patient sexual contact. Students were assigned to either intervention groups or control groups and responded to an anonymous questionnaire (overall response rate 66·8% ; n=141). As many as 14·5% of control group students thought it was (sometimes or usually) appropriate for general practitioners to date their own patients and at least 3% thought it appropriate for members of any of these three medical specialties to engage in sexual contact with their own patients. However, there were no significant differences in attitudes toward hugging, dating or sexual contact with current patients between those who had attended the seminar and the control groups. The session significantly influenced attitudes regarding obstetrician/gynaecologists and psychiatrists hugging and having sexual contact with former patients. These findings are discussed in relation to a need for expansion of such instruction.     

Teaching sociology of medicine: the group process

As a part of any curriculum reorganization, new instructional methods are also tested. When the University of Turku sociology of medicine course was found to need renovation, its goals and objectives, content and instructional methods were closely examined and modified, in order to strengthen institutional and multiprofessional relations and reinforce sociocultural issues in doctors' competence with the patient. This paper discusses this change, emphasizing teaching and learning methodology.     

An analysis of paediatric diagnostic decision-making: how should students be taught?

This study assesses the relative importance of history, examination and investigations in paediatric diagnosis, in the Paediatric Out-patient Department of the Central Middlesex Hospital, London, by means of a questionnaire-based record of 94 consecutive referrals. A diagnosis identical to the final diagnosis was made in 76% of referrals after taking a history. The general practitioner had proposed a diagnosis in 45% in the referral letter. Clinical examination changed the diagnosis in only 15% but increased diagnostic confidence in 33%. Ninety-one per cent of cases were diagnosed without recourse to investigations. Forty-two per cent of children referred had investigations performed. In the majority of paediatric cases the provisional diagnosis reached after taking a history was identical to that after examination or results of investigations were known. Although examination provided a final diagnosis in only 15% of all cases it played an important role in adding confidence in 33%. More educational effort should therefore be directed at clinical history-taking skills and the subsequent purpose of examination.