07-在社区和门诊环境下的教学.ppt

Teaching in Community and Ambulatory Settings 在社区和门诊环境下的教学,Warren Heffron M.D. Warren Heffron 医学博士 Professor Family Medicine全科医学教授 University of New Mexico新墨西哥大学 Albuquerque New Mexico. USA美国新墨西哥州阿尔布开克 In His Image Residency In His Image 住院医师培训指导老师 Tulsa, Oklahoma, USA 美国俄克拉马州塔尔萨市,Ambulatory Teaching 门诊教学,Increasingly important 日益重要 Balances education 平衡教育 Education for practice 实用性教育“real world” 真实世界 Almost any site where medicine is practiced can be used for teaching.几乎所有实践医学的地方都可以用来教学,What is learned?学什么？,Observe experienced physician deliver care观察有经验的医生提供医疗照顾 Provide care with supervision在督导下实践 Practice clinical skills 实践临床技能 Communication 交流 Not from lectures 不只从讲课中学习 The non hospital part of medicine 医学中和住院不相关的部分。,Problems问题,Inexperience 无经验 Time 时间 Observation 观察 Teaching 教学 Feedback 反馈,Benefits好处,Enjoyable 可享受的 Give something back to medicine返给医学一些东西 Teachers learn 教师学习 Learner time with patients 学习者和病人时间 Patient Education 病人教育 Counseling 咨询example: bruit and decreased pulse例子：心脏 杂音和减弱的脉搏,Patient Acceptance 病人接受性,Variable可变的 Importance of physician request医生要求的重要性,Include other sites/personnel 包括其他场所和人员,Any type of medical office or clinic 所有的医疗办公室和门诊 Occupational Medicine sites职业医学场所 Orphanages 孤儿院 Hospice安养院（临终关怀医院） Nursing home 养老院 Sports medicine sites 运动医学场所 Community medicine sites 社区医疗场所schools, prisons, etc. 学校、监狱等。,Sites / Staff 场所/职员,Community health workers社区医疗工作者 Community health educators 社区医疗培训人员 Social workers 社会工作者 Case managers 病例管理人员 Occupational therapists 职业治疗师 Physical therapists 理疗师 Counselors, Psychologists 咨询员、心理学家,Example 例子,Resident visits to rural villages outside of Shen Yang.住院医师拜访沈阳郊外的农村 Health care provided in local clinic当地门诊的医疗照顾情况 Orphanage visit, also in Haikou 福利院初诊；也在海口 Health education programs and surveys of needs of the community医疗教育项目和社区医疗需要调查。,Example例子,Good Samaritan Health Services. Tulsa, Oklahoma, USA 美国俄克拉马州塔尔萨市好撒玛利亚人医疗服务中心。 Mobile clinics in trucks specially built专门为大卡车司机设立的电话门诊服务。 Multiple sites on different days不同日期多个地点 Go where the poor are穷人去哪儿看病？ Multiple services, acute care, chronic care, women’s health 多种服务，急性病照顾、慢性病照顾、女性健康照顾。 Residents gain part of their education住院医师得到额外的教育。,Example例子,Rural based family medicine residencies.以乡村为基础的全科住院医师培训项目 3 year, 1+2 model in New Mexico, USA美国新墨西哥州1+2 、3年培训的模式 4 sites in rural areas around the state整个州在乡村的4个场所 Same curriculum as at the university和大学一样的课程 Residents learn well, pass certification exams 住院医师学得很好，通过资格考试。 Increased retention to serve in rural areas.服务乡村名额增加。,Imagine 想象一下,Your place of work as a place for teaching if you have any community activities or work outside of a large medical school假设你有一些社区活动或一个大医学院的工作外展，你的工作场所将会作为教学地点。 If not create such a place in your mind where you could go to do some teaching.如果你脑海里不能想象出这样一个地方 ，你会去哪儿作这样的教学？,Advance planning提前计划,Develop course syllabus确立课程表 Office/staff preparation诊室/同事准备 Arrange patients (permission) 安排病人（同意） Meet with learner-Orientation以学习者为导向Mutually develop goals, expectations共同确立目标、期望。Time plans and evaluation时间计划和评估Teaching / learning styles教/学方式,Active Process积极的过程,What can I teach?我能教什么？ What do you want to learn? 你想学什么？ Teach / learn from every encounter每一次病人来诊都教/学。,Costs 代价,Time, may increase day by 45 minutes时间，每天增加至45分钟。 Billing, may decrease by one patient账单，可能是少看一个病人的费用 Residents students 住院医师 学生 Considerably variable相当多不确定因素,Characteristics of a good teacher 一位好老师的特点,Knowledge知识 Availability可及性 Clinical competency临床能力 Desire to teach教的愿望 Good feedback skills好的反馈技巧 Organization skills组织技巧 Professionalism专业素养 Well prepared准备充分 Scholarly 博学,Enthusiasm 热情 Nonjudgmental不论断 Respects learner autonomy尊重学习者自主性 Sincerity 真诚 Listening skills倾听技巧 Role model角色榜样 Practices evidence based medicine实践循证医学,Characteristics特点,Patient 耐心的 Observant 善于观察 Good communicator 好的交流者 Stimulating 激发 Encouraging 鼓励,Characteristics of good teachers 好老师的特点,Delegate responsibility 给予责任 Communicate expectations 交流期望 Enthusiasm 热情 Stimulate interest 激发兴趣 Role models角色榜样 Excellent patient skills 出色的接诊病人技巧 Involve learner in process learning prescription让学习者参与学习过程中,At Beginning开始阶段,Review expectations, goals, objectives回顾期望、目的、目标 Ground rules 基本原则 Review competencies 回顾能力 Learner prescription 学习者处方 Get to know student personally认识学生个人,Teaching by direct observation 通过直接观察教授,May be intermittent 可能是间断性的 Opportunities for immediate feedback 立即反馈的机会 Review clinical notes 复习临床病例 Work together ie shared PE 一起工作，如：共同做体格检查。,Teaching by Example 通过例子教授,Role model角色榜样 Demonstration 展示History and PE 病史和体格检查Procedures 小手术 Then have learner demonstrate to you然后让学习者演示给你看,Teaching by indirect observation 通过直接观察教授,Feedback from patients 病人反馈 Feedback from staff 同事反馈 Video tape and review together 录像，一起复习,Areas for emphasis重点部分,Establishing a chief complaint 明确主诉 Multiple histories 多方面病史Past- med, surg, Rx, hospitalizations既往史、手术史、治疗、住院Family 家族史Allergies 过敏史Social 社会史Work 工作Sexual 性Spiritual 心灵/精神方面,Teaching Foci 教育聚焦,Review of Systems 系统回顾 Physical Exam 体格检查 Assessment 评估 Management plan 处理计划Acute or current 紧急的或目前的Health care management 健康处理Patient Education 病人教育,Ambulatory Learning Content 门诊学习内容,History multiple components 病史多方面的内容 Physical exam multiple components 体格检查多方面的内容 Problem identification 问题识别 Work up plan 制定计划 Management skills 应对技巧 Presentation skills 汇报病史技巧,Ambulatory Procedures,EKG 心电图 Pap test 子宫颈涂片检查 Colposcopy 阴道镜检查 Endometrial biopsy 子宫内膜活检 IUD insertio 宫内节育器植入 Skin biopsy 皮肤活检 Laceration repair 撕裂伤修复 OB ultrasound 产科超声,Casting 石膏固定 Splinting 夹板固定 Vasectomy 输精管切除术,Office management 门诊处理 Consultation skills 咨询技巧 Communication skills 交流技巧 School health issues 学校健康问题 Occupational medicine skills 职业医学技巧 Community resources 社区资源 All patient problems 所有病人问题,Spend time observing the learner花时间观察学习者 Reinforce what was done right强化做对的be specific 成为专业的 Correct mistakes 纠正做错的be specific 成为专业的,Preceptor should see the patient 督导老师应看病人 Check out and be responsible for care 核对且对医疗照顾负责 Address learner needs 注意学习者需要 Address patient needs 注意病人需要both have an agenda 两者都有安排,Efficiency tips 效率秘诀,Presenting in the room 在房间里汇报病史 Collaborating on physical exam 合作做体格检查 Active observation 积极观察 Service based education 服务为基础的教育 Self directed learning 自我导向的学习,Feedback 反馈,Constructive 建设性的 Regular 定期的 Suggestions for improvement 改善建议Sandwich method 三明治方法What was done right (reinforce) 做对的（加强）What was done wrong (correct)做错的（纠正）What to improve on next time 下一次要改善的,Office process 门诊过程,Learner history, exam and organize thoughts 学习者---病史、查体和整理思路 Present to preceptor 汇报给督导老师 Discuss findings 讨论结果 Plan management 计划处理,Process过程,Mutual questions 互相提问 Identify learning issues 明确要学习的问题 Mini lectures 小讲座 Learner self study and report later 学习者自我学习，然后再报告,Involve Evidence Based Medicine 应用询证医学,PICO format PICO形式Population 人群Intervention 干预Comparison 比较Outcome 结果,Population 人群,Who: An obese 45 years old female with Diabetes Mellitus Type 2 谁：一个患有2型糖尿病的45岁肥胖女性。,Intervention 干预,Patient is taking metformin 病人正在服用二甲双胍,Comparison比较,Does taking metformin compared with diet alone will help this patient?和单独饮食治疗相比，服用二甲双胍对这病人有帮助吗？,Outcome结果,Affect all-cause mortality 影响全因死亡率 Literature review indicated that patients aggressively treated with metformin compared with diet alone group had a 36% risk reduction for all cause mortality. 文献回顾显示：和单独饮食治疗组相比，服用二甲双胍积极治疗的那些病人全因死亡率风险下降36% 。 Therefore it would be appropriate to use metformin in this patient. 因此对这个病人来讲，服用二甲双胍是合适的。,Reasons for Evaluations评估理由,Identify learner’s strengths and weaknesses 明确学习者的强项和弱项 Determining competencies 确定能力 Make decisions regarding promotions & retentions 对升级和留级做出决定 Determining grades 确定级别 Provide information to outside institutions 为外边的机构提供信息 Recording legal documentation 记录合法文件,Learner Deficiencies学习者不足之处,Knowledge base 知识基础 Skills 技术 Professionalism 专业素养ACT EARLY 早行动,Evaluation评估,Continuous intermittent evaluations 持续的周期性评估 Dedicated final evaluation time 专门的最终评估时间verbal 口头written 书面,At End结束时,Measure achievements against original plans 针对最初计划进行成绩测定 Homework assignments 家庭作业分配 Specific projects 特别项目 Patient comments 病人评价 Learner self evaluation 学习者自我评估,Evaluation评估,Treatment plans 治疗计划 Social / behavioral areas 社会/ 行为方面 What can you learn from this case 你从这病例中学了什么 Learner attitude 学习者态度 Learner behaviors 学习者行为,RIME Evaluation RIME式评估,R. Reporter R 报告者 I. Interpreter I 翻译者 M. Manager M 管理者 E. Educator E 教育者,Improving Yourself 改进和提高自己,Workshops 参加研讨班 Courses 参加课程 Peer site visits 同事工作场所拜访 Self evaluation 自我评估 Learner evaluation 学员评估,Resources资料来源,Teaching in your office. By Alguire, Dewitt, Pinsky and Ferenchick. 门诊教学， By Alguire, Dewitt, Pinsky and Ferenchick. On line clinical teaching, Morrison et alFamily Medicine Jan 2005在线门诊教学。Morrison et alFamily Medicine Jan 2005,Teacher vs Educator 老师与教育者,Teen age girls and lipstick on the mirror- had janitor show them how he removed the smears with toilet water. Never happened again. 十几岁的女孩和镜子上的口红——让管理者给她们示范如何用厕所水除去那些口红印。再也不会这种情况。,