全科医师教育培训与评估 Training and Assessment for General Practitioners 复旦大学医学院全科医学系 复旦大学附属中山医院全科医学科 祝墡珠教授 Zhu Shanzhu Faculty of General Practice, FuDan Medicine Institute Department of General Practice, ZhongShan Hospital affiliated to FuDan University

背景 Background： 据统计，所有到医院就诊的患者中只有5%左右需要专科医师的诊治，而人群中80％~90%的健康问题可以由以全科医师（家庭医师）为骨干的社区卫生服务队伍来解决 According to the recent statistics, only 5% of the patients who go to hospital need the health-care from specialists, and 80%~90% health problems can be solved by GPs-based community health-care system

发达国家的实践经验也告诉我们：控制医疗费用，有效利用有限的医疗保险资源的关键措施是发展以全科医师为骨干的社区卫生服务 近10年来，我们致力于毕业后全科医师的教育培训，探索建立新型的全科医师教育培训与评估模式 The experience gained in developed countries reinforces the idea that to develop GPs-based health-care in community setting is a crucial measure to reduce medical costs and make use of the limited resources of Medicare more effectively In the recent decade, we have devoted ourselves to training GPs and developing a workable system for GPs’ training and assessment in the past decade

研究目的 Research Objective： 在综合性教学医院进行全科医师规范化培训的探索，建立适应生物－心理－社会医学模式的新型教学方式，取代专科医学以知识和技能掌握为重点、以疾病为中心的传统教学模式 To develop a new efficient system for standardized GPs’ training in comprehensive teaching hospital, corresponding with biological-psychological-social medical pattern and reforming the disease-oriented traditional system which focuses solely on medical knowledge and skills

研究方法 Research Method 对象 以高等院校临床医学本科毕业，有志于从事社区卫生服务工作的医师为培训对象 Objects We recruit students graduated from medical universities as our trainees, who have obtained bachelor degrees in clinical medicine, and willing to become GPs

方法 参考发达国家和地区的培训要求，结合我院多年的住院医师培训经验，制定全科医师规范化培训大纲和要求、考核内容和评估方法。在教学实施过程中不断接受来自培训者和受训者的反馈意见，对培训和考核的方法、内容进行改进和完善 Methods We tried to work-out a new set of regulations, a curriculum for standardized GPs’ training, the methods of examination and assessment, which drew on GPs’ training methods in the developed country and district, as well as the long-term residents’ training experience of our hospital .During the process, we tried to improve the methods of teaching and the content of the training courses and assessment step by step through collecting constructive feedback from the trainers and the trainees

培训方法 Training Methods 分理论学习、临床轮转和社区实践三个阶段 理论课程分别由资深全科医师和专科医师担任授课，并邀请美、英、中国台湾等地的资深全科医师来访讲学 The training process involved 3 phases: academic learning, clinical rotation and community practice Senior GPs and specialists assumed the teaching tasks together in academic curriculum. At the same time, we invited sophisticated GPs coming from Taiwan, UK, US to hold a course of lectures

临床轮转要求病区主治以上医师带教，由我院全科医学科负责教学的医师（副高职称）全程监控，及时掌握学员的反馈信息，与带教老师协调 Attending doctors in wards took charge of trainees’ clinical rotation and adjunct professor of Department of General Practice, with responsibility for training, supervised the whole course, who would learn from the feedback from trainees in time and coordinate with the supervisors of all wards

培训方法 Training Methods 社区实践期间，学员由所在社区的资深医师带教。带教老师先由我科统一进行全科医学理论的培训，并通过电话联系、每半年度集中座谈等方式及时反映社区带教过程中遇到的问题。学员则每周回我科集中1次，利于双向交流 During community practice, the senior physicians in community would supervise our trainees, who received the academic training of General Practice in advance and reflected the existing problems in trainees’ practice through frequent telephone communication and rap sessions every half an year. Trainees came back to our hospital every week so as to communicate with us

学年结束，举行学员座谈会，听取学员意见和建议，改进培训方法 When academic year was over, we would hold a session for trainees, collecting constructive ideas and suggestions, to improve training methods

培训内容和期限 Training Contents and Schedule 培训围绕以下六方面的能力培养 1.患者的照顾 2.医学知识的掌握 3.实践中的学习和提高 4.人际交流 5.职业道德 6.立足于卫生保健系统的医疗行为,为期4年 It took 4 years to perform the training based on six aspects as follow: patient care, medical knowledge, practice-based learning and improvement, interpersonal communication skills, professionalism and health-care system-based practice

培训内容和期限 Training Contents and Schedule 理论课程2个月，包括全科医学概论、预防医学、综合课程（社区诊所的管理、社区合理用药、老年病学、医患交流技巧及计算机应用课程等）和专业英语 Academic courses took 2 months, including Panorama of General Practice, Preventive Medicine, comprehensive courses (such as management of clinic in community, rational prescription in community clinic, Geriatrics, skills of physician-patient communication and computer application as well) and medical specialized English

临床轮转26个月，包括内、外、妇、儿、急诊科、五官科、皮肤科、眼科、康复科、中医科、CDC等 社区实践20个月 轮转期间每月安排学员集中1次，讲授临床医学进展 Clinical rotation took 26 months, including department of Internal Medicine, Surgery, Gynecology & Obstetrics, Pediatrics, Emergency, ENT, Dermatology, Ophthalmology, Rehabilitation, Traditional Medicine, CDC and Psychology etc. Community practice took 20 months We held a seminar every month to introduce the advancement of clinical medicine for trainees

考核和评估 Examination and Assessment 围绕上述6方面的能力培养，制定相关知识、技能和态度要求，以及相应的考核和评估表格：如病史质量评估表、临床能力考评表、医师接诊评估表、文献综述评估表、医患交流患者评估表、医患交流患者家属评估表、同事评价表、职业道德评价表等，每半年考评1次，由全科教学组完成对学员的考评 According to the 6 aspects we mentioned above, we worked-out relevant requirements of knowledge, skills and attitudes, as well as examination and assessment forms respective: such as case history quality assessment form, clinical ability testing form, literature and review assessment form, physician-patient communication assessment form, patient’s relative-based communication assessment form, co-workers' evaluation form and professional morality evaluation form etc. These examinations and assessments were performed by educational group of our department and relevant professionals every half an year

考核和评估 Examination and Assessment 阶段考核：各阶段培训结束后，由我科组织相应的理论和临床技能考核，并将考核结果记录在培训手册上 Stage examinations: When every phase was over, our department would organize examinations of corresponding academic knowledge and clinical skills, recording the traines’ scores on the manuals

综合考核：培训结束后，要求学员完成以社区为基础的论文一篇，通过论文答辩并结合既往考评结果，成绩合格者将获得卫生部颁发的全科医师规范化培训合格证书 Comprehensive examinations: When the whole training was over, trainees were required to hand in a paper based on community setting. Those who went through the defending smoothly and past assessments were eligible will acquire qualification certificates for GPs’ training issued by the Healthcare Ministry

结果 Results 建立全科医师规范化培训的模式 制定相应的教学大纲、教学计划、教学管理文件和教学效果评估方法 主编多部全科医师培训教材：如《全科医学概论》（第二版）；《全科医学导论》（第一版）；《社区常见健康问题》（第二版）等 Formulated a training pattern for GPs Worked out a training curriculum, scheme, administration and assessing methods Published several textbooks for GPs’ training

从2000年12月至2005年9月举办了6期毕业后全科医师规范化培训，共招收165名学员。迄今有70名学员完成培训，通过各项考核，获得全科医师规范化培训合格证书 From Dec.2000 to Sep.2005, standardized GPs’ training courses have been run for 6 times, in which 165 students have been enrolled and 70 students have passed all the examinations and acquired the qualification certificates for GPs’ training

讨论 Discussion 目前，全科医师规范化培训仍处出于探索阶段，培养合格的全科医师是社区卫生服务可持续发展的关键。我院全科医学科多年来致力于全科医学教育，旨在培养高素质的全科医师，充实全科医师及其师资队伍 At present, we are still exploring the standardized GPs’ training. Qualified GPs are crucial for the sustainable development of community health-care system. We devoted ourselves in the past decade to training eligible GPs so as to enforce the team of GPs and trainers

全科医师教育培训的重点在于培养全科医师提供合理、有效、人性化医疗照顾的能力，以及寻找、评价和利用最佳医疗方案，解决患者健康问题的能力，以适应社区卫生服务发展的需求 The training for GPs should focus on developing students’ comprehensive ability (including offering rational, effective and individual health-care as well as managing health problems through assessing and adopting best medical methods), accommodating to the need of community health-care service

讨论 Discussion • 综合性教学医院有着得天独厚的教学条件，在全科医学的教育培训中担负不可或缺的责任 • 全科医学教育离不开专科医师的作用，然专科医师若未经过相关的全科知识培训，其专科医疗的临床思维方式在一定程度上将影响全科医师的培训质量 GPs’ training can best be done in comprehensive teaching hospitals where there are superior educational resources, which will help to enhance GPs’ training programs Specialists play an important role in General Practice education, whose special medical ideas will effect the quality of GPs’ training unless they receive academic education from experienced GPs

目前的培训评估大多通过调查问卷的方式，缺乏客观标准，培训的优劣将难以彰显 In general, we assess the training quality by questionnaire, lack o objective standard, which couldn’t evaluate the merits and weakness objectively of training pattern

讨论 Discussion 由于目前全科医师的社会地位不高，经济收入低下，导致培训生源不足，生源质量得不到保障；培训过程中学员流失 At present, GPs’ social status and income aren’t satisfied, on account of which, there’re not enough trainees for GPs’ training and the quality of trainees couldn’t be ensured, furthermore a part of trainees will leave school during the training

政府应增加对全科医学培训的投入：在高等医学院校成立全科医学系；从政策、财政两方面保障全科培训的开展；借助媒体宣扬全科医学，争取全社会的支持；切实提高全科医师的社会和经济地位 Government should reinforce the General Practice education: to set up the department of General Practice in medical university; to ensure the implement of GPs’ training by policy and financial subsidization; to publicize General Practice by media and gain the support of the Public; so as to enhance the GPs’ social and economic position

总之，随着我国医疗体制的深入改革，全科医师教育日益显示其重要性。综合性医院率先进行这方面的探索，有助于改进和完善全科医师培养模式，尽快建立1支能满足广大居民基本医疗保健服务的全科医师队伍 GPs’ education is becoming more and more important with the modernization of Medicare system in our country. GPs’ training done in comprehensive teaching hospitals will help to enhance GPs’ training programs and provide a team composed of GPs satisfying the basic health-care needs of the Public

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