北京协和医学院八年制医学生 皮肤病学临床轮转及对皮肤病学病例库需求的调查

目的调查北京协和医学院八年制见实习临床医学生轮转皮肤科的教学需求、实际效果及对皮肤病学病例库的需求。方法从2017年1月至2019年1月对北京协和医学院2011级至2014级八年制轮转皮肤科的临床医学生发放问卷,调查其对皮肤科临床轮转的需求、轮转时的学习难度、轮转后对知识的掌握程度及对建立皮肤病学病例库的需求。结果共收到有效问卷101份,八年制临床医学生轮转皮肤科期间最希望学习的内容为常见及疑难皮肤病的诊断和治疗,其次为医学美容;临床轮转中,学习难度最大的内容为自身免疫性大疱病;临床轮转后,对皮肤病学知识的掌握程度仍有待进一步提高;对皮肤病学病例库的需求非常强烈,希望以电子病例库形式共享,最感兴趣的内容为变态反应性皮肤病。结论明确了北京协和医学院八年制临床医学生皮肤病学教学中的兴趣点和难点,了解了其对皮肤病学病例库的实际使用需求,有利于皮肤病学教学模式的进一步改进。     

局部解剖学上、下肢典型病例库的构建与应用

建立规范的病例库是深入CBL教学法的重要环节.我们构建了局部解剖学上、下肢病例库,分为小病例、大病例和对比性病例,与LBL教学法融合进行教学.学生在准备和讨论病例相关问题的过程中,可以综合锻炼检索能力、团队合作能力和分析总结能力.后疫情时代,在线下和线上的上、下肢教学中使用病例库,符合学生学以致用的心理,能提高教学效率,改善教学效果,提高临床思维能力.     

基于PACS的MRI影像多媒体教学与报告系统的研究

目的：开发基于医院影像归档和通讯系统（picture archiving and communication system，PACS）环境的MRI（磁共振显像）影像多媒体教学与报告系统。方法：医院PACS系统符合DICOM3.0标准，采用1000M光纤主干网，100M交换到桌面；在临床医生浏览工作站安装多媒体教学系统，在诊断工作站安装教学系统与报告系统；科学内容按部位分类，以树枝模式管理。教学字资料来源于具有一定权威的教科书、专及期刊。图像资料来源于各部位经病理及临床证实的病例，直接从PACS系统提取，经标注说明后，以件形式存放于PACS图像服务器硬盘。结果：MRI辅助影响教学系统能够实时调阅最合适病种的MRI征象、临床特点、病理、鉴别诊断、典型图像及注释、正常断面解剖等，供教学、诊断和报告参考。结论：PACS环境下MRI辅助影像学系统，能满足临床医生和低年资影像诊断医生对MRI影像知识进一步继续医学教育的需求，能为影像诊断医生提供教学及科研工具，提高MR室工作质量和工作效率。     

消化性疾病诊疗专家系统

在参考美国MYCIN专家系统的基础上〔1〕,设计了对消化性疾病的腹痛、腹水、上消化道出血、黄疸和腹泻等五个症状的二十五种疾病进行诊断和治疗的专家系统〔2〕。该系统结构为知识获取、知识表达、推理机、知识储存(症状库、病历库、矩阵库),还具有知识更新、统计、咨询以及解释功能〔3〕。经对100例腹水病例进行回顾性验证,符合率达100％;对其它各病进行验证的符合率也高于90％。     

局部解剖学有机结合临床病例的教学方法探讨

在局部解剖学教学过程中，将解剖学知识与I临床病例有机结合，加强解剖学知识的实用性，提高解剖学教学效果。     

病理学诊断的局限性

1　病理学诊断及其重要性诊断是治疗的前提。Ｄｉａｇｎｏｓｉｓ原意是通过辨识进行判断。医学中译作诊断 ,表示通过病情学(ｎｏｓｏｇｒａｐｈｙ)、体征学及其它医学检查手段以判断疾病本质和确定疾病名称的过程〔1〕。病理学检查是辨识形态变化、确定患病部位、认识疾病本质的最有效手段。病理学诊断是病理医师应用病理学知识和方法 ,对临床医师送检标本进行检查 ,结合临床资料 ,通过分析、综合、判断获得的对具体病例所患疾病本质认识的概括。病理学诊断对许多疾病的确诊、治疗方案的选择和预后的判断 ,具有重要的有时甚至是决定性的意义…     

基于病例的学习在核医学教学中的应用

基于病例的学习是病例教学的重要组成部分，我单位开展形式为教学读片及疑难病例读片。本文采用问卷调查的方法，就读片在知识和个人能力提高方面的评价，对62名参与读片者的调查问卷结果作出分析。结果显示基于病例的学习在核医学教学中有助于学员更好地掌握基础知识、提高临床思维以及增加学习主动性，并更加具有实用性，提高解决临床实际问题的效率，有助于学员更顺利的完成住院医师规范化培训。因而基于病例的学习可以为核医学医师培训提供更好的学习体验和教育效果。     

家庭护理工程数据管理系统

家庭护理工程数据管理系统是将临床采集的各种数据通过中心机和网络传输到数据库，并与库中已存在的该病人的病例号相吻合后纳入相应的表和库中，医生可根据统计结果及综合情况给出医疗方案并可将医嘱直接传送到临床。数据管理系统除与中心机双向网络传输外，还包括病人及家族等的各种信息。     

2006年1至8月份我国克雅病监测病例分析

目的了解我国克雅病（Creutzfeldt-Jakob disease，CJD）的发病情况及分布特征。方法对2006年1至8月份我国克雅病监测网络获得的可疑CJD病例的l临床及流行病学资料进行分析；收集患者脑脊液及血液样品，利用Western Blot方法对脑脊液中14—3—3蛋白进行检测；利用PCR及测序方法对脚基因进行序列分析。结果共发现CJD临床诊断病例10例，疑似诊断病例8例。均为散发型CJD病例，病例的地理分布及职业没有明显的聚集性。发病年龄平均为60岁，男女比例接近1：1。首发症状中以快速进行性痴呆所占比例最多，占44％。临床诊断病例比疑似诊断病例出现更多的典型临床表现。结论我国监测到的CJD病例主要以散发型为主，地理、职业、男女比例以及平均年龄均符合散发型CJD的分布特点。     

脊髓损伤定位诊断的局部解剖学教学

脊髓损伤的定位诊断对解剖学要求很高,临床应用解剖学教学需要将系统解剖和局部解剖学与临床知识相结合[1]。作者基于对临床医生的临床教学经验,讲解下列脊髓损伤定位诊断的局部解剖学知识,取得了良好的效果,现报告如下。     

基于医学本体的临床路径知识库模型建设

目的建立临床路径知识库模型,提高临床路径软件的自适应性,提升电子病历应用水平。方法利用本体知识库编辑工具,从医院已有的临床路径病种数据应用出发,对临床知识库内容进行规范化研究和标准化表达,形成临床路径知识库模型。结果建立了58个病种的临床路径知识库,该知识库描述了医院临床路径内容的各个方面,可应用于新一代临床信息系统建设。结论临床路径本体知识库对智能化电子病历应用和临床决策支持系统有重要作用,有利于医院信息系统的语义集成,是新一代电子病历应用的重要组成部分。     

Desiderata for product labeling of medical expert systems

The proliferation and increasing complexity of medical expert systems raise ethical and legal concerns about the ability of practitioners to protect their patients from defective or misused software. Appropriate product labeling of expert systems can help clinical users to understand software indications and limitations. Mechanisms of action and knowledge representation schema should be explained in layperson's terminology. User qualifications and resources available for acquiring the skills necessary to understand and critique the system output should be listed. The processes used for building and maintaining the system's knowledge base are key determinants of the product's quality, and should be carefully documented. To meet these desiderata, a printed label is insufficient. The authors suggest a new, more active, model of product labeling for medical expert systems that involves embedding `knowledge of the knowledge base', creating user-specific data, and sharing global information using the Internet.     

Development of decision making rules for transportable, microcomputer-based expert systems in medicine.

Computerized decision making aids have been developed for use in certain medical specialties over the last decade. These programs are designed to give expert-level advice within their limited domains. Two major components are required in the design of these systems: development of software and development of a knowledge base to handle the specific medical application. The advantage of the knowledge-based approach is that the application can be changed by replacement of the knowledge base, without requiring changes to the software. In this paper, EMERGE, a medical decision making system, originally developed for analysis of chest pain in the emergency room environment, is described. EMERGE uses production rules for representation of its knowledge base. The method by which this system can accommodate new rule bases for other applications is emphasized, as well as the transportability of the system.     

临床互动式教学在病理生理学教学中的运用

目的为了更好地培养将基础医学理论学以致用的优秀医学人才,病理生理学教学应改进教学方法、紧密结合临床、以提高学生学习兴趣和教学质量。方法在病理生理学教学过程中发挥教师带教优势,采用多种教学方法,如开展以问题为基础的教学,进行临床病例分析,结合多媒体教具运用等。结果在病理生理学教学过程中将基础医学理论与临床实际紧密结合,更有利于学生对医学基础理论的掌握,以及在临床中运用所学知识发现并解决问题。结论临床互动式教学适宜运用到病理生理学教学中去。     

医学研究方法与临床教学融合可行性调查

目的为开展临床与医学研究方法学教学融合,需要了解学生对于医学研究方法学知识的需求状况、掌握情况、影响学习的主要因素及如何才能有效的学习。方法通过问卷法调查已进入临床实习的协和八年制7年级学生、临床型研究生、规培住院医生及进入北京协和医院学习的进修医生。收集被调查者教育背景及医学研究方法学相关知识掌握现状、影响学习因素、学习内容需求、学习方式及课后考核方法信息。结果总计69人接受调查。92.75%学生曾经学习过医学研究方法学相关理论课程;但无法进行有效文献批判性阅读者达51人(73.91%);52人(75.37%)表示在进行研究设计时有困难;84.06%学生认为临床医生非常有必要学习研究方法学相关知识。影响学习的主要原因:临床工作太忙(57.97%)、无学习机会及资源(36.23%)。按学习需求度排名前3位的内容分别是样本量计算及统计学知识(71.01%)、如何选取研究设计类型(66.67%)及统计学软件的应用(63.77%)。44人(63.77%)希望通过网络与案例结合的学习及考核方式。结论临床融合医学研究方法学教学的需求度高,网络与案例结合的学习及考核方式更能够被学生接受,获得更好教学效果。     

生物医学仿真模拟及其在超声医学教学中的应用

目前,我国医学教育大多采用教师课堂授课、课后学生复习背诵所学知识的传统教学模式,临床技能培养主要采用师带徒式传承.虽然这些教学方法能较好地传授知识和技能,但在团队协作、知识整合、标准化训练等方面存在诸多缺陷.生物医学仿真模拟教学作为一种新型传授医学知识和培养临床技能的教学方法,已在现行医学教学中取得良好效果.拟从仿真模拟教学的定义、仿真模拟教学特点以及此方法在超声医学教学中的应用和价值进行综述.     

Co‐occurring medical conditions in adults with Down syndrome: A systematic review toward the development of health care guidelines

Adults with Down syndrome (DS) represent a unique population who are in need of clinical guidelines to address their medical care. The United States Preventive Service Task Force (USPSTF) has developed criteria for prioritizing conditions of public health importance with the potential for providing screening recommendations to improve clinical care. The quality of existing evidence needed to inform clinical guidelines has not been previously reviewed. Using the National Library of Medicine (NLM) database PubMed, we first identified 18 peer reviewed articles that addressed co‐occurring medical conditions in adults with DS. Those conditions discussed in over half of the articles were prioritized for further review. Second, we performed detailed literature searches on these specific conditions. To inform the search strategy and review process a series of key questions were formulated a priori. The quality of available evidence was then graded and knowledge gaps were identified. The number of participating adults and the design of clinical studies varied by condition and were often inadequate for answering all of our key questions. We provide data on thyroid disease, cervical spine disease, hearing impairment, overweight‐obesity, sleep apnea, congenital heart disease, and osteopenia‐osteoporosis. Minimal evidence demonstrates massive gaps in our clinical knowledge that compromises clinical decision‐making and management of these medically complex individuals. The development of evidence‐based clinical guidance will require an expanded clinical knowledge‐base in order to move forward.     

动脉血气分析和治疗建议软件的开发和应用

目的 开发一种可以快速、准确判断呼吸衰竭和酸碱失衡类型并提出相应治疗建议的动脉血气分析软件。方法 用Delphi7．0编写全部程序，适用Windows98、2000和XP操作系统。使用MicrosoftAeess建立数据库。运用相关知识和公式建立知识库和推理判断库。结果 本软件由动脉血气图分析、酸碱紊乱分型、电解质紊乱判断和呼吸衰竭分型等功能模块组成，并能对呼吸衰竭、酸碱紊乱和电解质紊乱等提出治疗建议，临床使用表明可快速判断呼吸衰竭、酸碱失衡并对治疗提出建议。结论 本软件界面简洁，操作方便，结果准确可靠，分析时间短，在临床有较大的实用价值。     

Preparing medical students to teach.

OBJECTIVE: Residents do a significant amount of teaching. Therefore, as medical students prepare for the clinical aspects of their residency, it is also important for them to prepare for their role of physician as teacher. With the goal of offering fourth-year students an opportunity to enhance their teaching skills, an elective was designed that presented them with an opportunity to expand their knowledge base in education, and then apply and practice this new set of knowledge. A week-long elective, Physician as Teacher, was designed to encompass core educational information such as needs assessment of learners, establishing goals and objectives, teaching methods, and evaluation and feedback. This core information was then applied and enriched during an end-of-course teaching presentation. Aside from this course, there is no forum during their undergraduate medical training for the students to acquire knowledge and skills about how to be teachers. DESCRIPTION: The course was developed with the appreciation that application of knowledge is a rich source of learning. The course began with interactive classroom teaching sessions designed to facilitate acquisition of core educational knowledge. Sessions topics included assessment of learner needs, methods of teaching, learning styles, microprecepting, and feedback. Also incorporated were sessions on facilitating small groups, and teaching and learning how to use technology. Those classroom sessions were then enhanced by a complement of sessions that asked the students to apply their new knowledge to clinical situations. Those more application-based sessions included observation and follow-up discussion of clinical teaching and small-group teaching sessions with the goal of developing the students' skills with respect to the teaching and learning process. An end-of-course teaching presentation by each student provided them with a capstone experience of applying the knowledge and skills learned throughout the week. The topic of the teaching presentation was of their choosing, and could incorporate technology. Each student's teaching presentation was videotaped, immediately viewed by the student, and discussed using a structured format of facilitated feedback. DISCUSSION: Students reported that the end-of-course teaching presentation was a rich source of their learning, and an important vehicle for helping them apply and synthesize the new knowledge. Fifteen percent of fourth-year students enrolled in and completed the elective. Seventy-one percent of those students "strongly agreed" and 29% "agreed" that the course provided useful knowledge and skills. Seventy-nine percent "strongly agreed" and 21% "agreed" that their teaching would be better because of the course. Based on comments, the students appeared to feel that the experience of presenting a teaching session at the end of the course was a rich source of their learning, and helped them to apply and synthesize the new knowledge. Students noted, "the teaching project was an excellent idea to see how much we have learned; I never realized what a responsibility we have as residents to teach our peers; I have been enlightened this past week and will now consciously make an effort to share what little information I currently have; I will be a better teacher because I have been given the appropriate tools."     

Development of a teaching program in clinical medical ethics at the University of Chicago

The University of Chicago Pritzker School of Medicine has developed and evaluated an extensive teaching program in clinical ethics coordinated primarily through the Center for Clinical Medical Ethics. The program provides medical students with a foundation in medical ethics during the four years of medical school and augments the clinical ethics knowledge and teaching skills of the housestaff and clinical faculty at the University of Chicago. Together, medical student teaching and clinical faculty development have made clinical ethics an integral part of medical education at the University of Chicago. Through these efforts, the teaching program aims to incorporate clinical ethics considerations into medical decisions and in this way contribute to improving patient care. (A detailed overview of all clinical ethics instruction at the school is provided.)