The Medical Care of Older Patients

Proper medical care for growing numbers of older people depends upon application of advances in medicine to the special problems of ageing. Despite gaps in understanding of the ageing process, high-quality care can be achieved through routine use of knowledge already available.Older people differ structurally, functionally and psychologically. Health influences every aspect of their lives. Their reactions to stress and disease are altered. In practice, the doctor must assess the biological changes of ageing and their possible influences on symptoms and signs. Modifications in the application of ordinary methods of medicine and surgery are determined by functional impairments and structural defects. While the medical problems of the aged are special, the approach must be general; the practitioner needs experience with disease in all age groups and should be alert to the adverse effects on old people of the universal misunderstandings of ageing and its problems.     

对重症医学科进修生的临床教学体会

重症医学在我国发展较为滞后,多数重症医学科医生来自于其他专业,缺乏重症医学专业知识及临床实践经验。建立完善、科学、有效的重症医学科进修生管理和培养模式对于进一步提高危重症救治专业人才的水平至关重要。我科室通过总结多年的进修生教学经验,以"病例分析学习(case based learning,CBL)+多学科协作(multiple department team,MDT)"教学模式为主导,以病例幻灯竞赛为契机激发进修医生学习的主观能动性;以专业英语为特色;重视临床科研教学;制定规范化培训制度,实行导师负责制,开展定期考核。显著提高了重症医学科进修生的医疗及科研水平。     

医学模拟教学结合以问题为导向的教学模式在重症医学教学中的应用研究

目的:探讨医学模拟教学结合以问题为导向(PBL)的教学模式在重症医学教学中的应用价值。方法:选取2015年1月~2017年1月在我院重症医学科轮转实习的五年制医学生64人作为研究对象。按随机数字表法将64名医学生分为PBL组(n=32)和结合教学组(n=32)。PBL组采用PBL教学,结合教学组采用医学模拟结合PBL教学。分别在入科时和轮转实习结束时对两组学员进行理论考试和技能操作考核,记录成绩并比较。理论考试和技能操作考核后采取发放问卷进行调查的形式获得学员对教学效果的主观评价。结果:轮转实习结束时,两组理论考试分数差异无统计学意义(P0.05);而结合教学组技能操作考核成分数显著高于PBL组,差异具有统计学意义(P0.05)。两组学员在教学方法接受度高、学习兴趣提升、自学能力提升和临床诊疗水平提高所占比例差异无统计学意义(P0.05);结合教学组学员在团队协作能力提高、沟通能力与人文关怀提高和技能操作水平提高所占比例高于PBL组,差异有统计学意义(P0.05)。结论:与单独PBL教学相比较,医学模拟教学结合PBL的教学模式应用于重症医学教学对学员技能操作的掌握有更好的效果,同时能提高学员团队协作能力、沟通能力以及对患者的人文关怀,且受到学员的认同与喜爱,应在重症医学的教学实践中逐步完善并进一步推广应用。     

Patient Perspectives on the Experience of Being Newly Diagnosed with HIV in the Emergency Department/Urgent Care Clinic of a Public Hospital

We sought to understand patient perceptions of the emergency department/urgent care (ED/UC) HIV diagnosis experience as well as factors that may promote or discourage linkage to HIV care. We conducted in-depth interviews with patients (n=24) whose HIV infection was diagnosed in the ED/UC of a public hospital in San Francisco at least six months prior and who linked to HIV care at the hospital HIV clinic. Key diagnosis experience themes included physical discomfort and limited functionality, presence of comorbid diagnoses, a wide spectrum of HIV risk perception, and feelings of isolation and anxiety. Patients diagnosed with HIV in the ED/UC may not have their desired emotional supports with them, either because they are alone or they are with family members or friends to whom they do not want to immediately disclose. Other patients may have no one they can rely on for immediate support. Nearly all participants described compassionate disclosure of test results by ED/UC providers, although several noted logistical issues that complicated the disclosure experience. Key linkage to care themes included the importance of continuity between the testing site and HIV care, hospital admission as an opportunity for support and HIV education, and thoughtful matching by linkage staff to a primary care provider. ED/UC clinicians and testing programs should be sensitive to the unique roles of sickness, risk perception, and isolation in the ED/UC diagnosis experience, as these things may delay acceptance of HIV diagnosis. The disclosure and linkage to care experience is crucial in forming patient attitudes towards HIV and HIV care, thus staff involved in disclosure and linkage activities should be trained to deliver compassionate, informed, and thoughtful care that bridges HIV testing and treatment sites.     

Integrate personalized medicine into clinical practice to improve patient safety

Medical practice is based on the experience of practitioners and on learned medical knowledge. This knowledge is based on studies of patient's population. Modern medicine is facing a variety of clinical forms and also variable patients’ responses to treatment. Pharmacogenomics has brought insights to this variability and has led to the development of personalized medicine. The adoption of personalized medicine is slowed down by a number of technical and methodology barriers. The concept of personalized medicine should not be only limited to genetics but must reuse all patient information to get the most suitable patient profile. In this paper we present a methodology for the integration of personalized medicine into clinical practice.     

The management of allergic patients; the role of the internist

There has been an increasing trend in the United States toward intensive specialization in allergic diseases. Whereas the tendency toward specialization has led to greater knowledge of the scientific aspects of allergic phenomena, it has somewhat diverted the specialists' attention from the many clinical problems that await solution. Effective treatment of the allergic patient depends in no small measure on the broad viewpoint and clinical experience of the internist. This fact has been reemphasized by the growing awareness of the significance of the secondary or precipitating causes, such as climatic, nutritional, hormonal and psychogenic factors which influence allergic manifestations. Overemphasis on specialization in allergic diseases with their wide ramifications may defeat the main objective-a successful therapeutic result. To meet this challenge, the internist should be trained in allergy and yet retain a broad approach to the more basic problems of internal medicine. This objective may be attained by certain modifications in undergraduate medical instruction in allergy. Postgraduate training sponsored by our national allergy societies affords internists an excellent opportunity to advance their knowledge of clinical allergy.     

The role of deputizing agencies in the delivery of primary health care services.

When not available to their patients, family practitioners in large cities can "sign out" to deputizing agencies, which coordinate the activities of part-time physicians on call. The physicians making use of one such agency in Toronto appeared to be representative of family practitioners in the region. One thousand of their patients seen consecutively by one physician were asked a series of questions. The majority of the 811 evaluable patients were considered to have problems justifying an after-hours call, although 16% of the problems were of a trivial nature. However, almost half of the patients with trivial problems would have gone to the local emergency room, as would 85% of all the patients. Although virtually all (94%) of the visits with the elderly were justified, 34% of the patients in this age group said they probably or definitely would not have sought emergency room care if a physician had not been available. The use of deputizing agencies should reduce the overuse of emergency room facilities and provide optimal after-hours primary medical care.     

“THAT’S NOT HIS ONLY PROBLEM...” CLINICAL TEAMWORK IN A PSYCHIATRIC EMERGENCY ROOM

This article is a qualitative study of the social organization of clinical work in a psychiatric emergency room. The research involved observation of emergency room practices and interviews with the clinical staff members. Due to responsibility of ensuring confidentiality, audio taping was not possible. Observations and interviews were recorded by hand, and thus, except in brief instances, I describe talk rather than reproduce it verbatim. Psychiatry, I argue, should not be explored as a singular profession but as the team practice of a team of occupational groups. These groups are often seen as subordinate to psychiatric physicians, but as this paper will demonstrate these groups are often able to call upon their specific claims to expert knowledge to assume clinical authority over a patient’s diagnosis and treatment. The successful pursuit of such a claim puts these clinical occupational groups in a position to challenge psychiatrists over crucial hospital resources such as beds. These groups’ claim to authority emerges from two sources. The first is their specific histories and their clinical knowledge systems that initially developed independently of cosmopolitan medicine. The second is the political economic environment of urban hospital psychiatric departments which largely treat patients with opaque symptoms of unclear origin that defy easy psychiatric classification.     

妇产科住院医师培训模式探讨及效果评价

目的 进行妇产科住院医师培训模式探讨及效果评价。方法 采取调查问卷，考核结果统计学处理等方法。结果 超过80%人员认为进行心内科、外科、急诊科轮转很有必要，时间分别为3、3、6个月适宜。参加相关科室轮转的住院医师与未参加者在执业医师、妇产科第一、二阶段临床技能考核通过率无差异，数值上参加相关科室轮转者高于未参加者。在辅助检查上，参加相关科室轮转者高于未参加者，差异具有统计学意义。结论 建议妇产科住院医师进行相关科室轮转，科室为心内科、外科及急诊科，时间分别为3、3、6个月，可增加临床知识的广度。     

THE MANAGEMENT OF ALLERGIC PATIENTS—The Role of the Internist

There has been an increasing trend in the United States toward intensive specialization in allergic diseases. Whereas the tendency toward specialization has led to greater knowledge of the scientific aspects of allergic phenomena, it has somewhat diverted the specialists'' attention from the many clinical problems that await solution.Effective treatment of the allergic patient depends in no small measure on the broad viewpoint and clinical experience of the internist. This fact has been reemphasized by the growing awareness of the significance of the secondary or precipitating causes, such as climatic, nutritional, hormonal and psychogenic factors which influence allergic manifestations. Overemphasis on specialization in allergic diseases with their wide ramifications may defeat the main objective—a successful therapeutic result.To meet this challenge, the internist should be trained in allergy and yet retain a broad approach to the more basic problems of internal medicine. This objective may be attained by certain modifications in undergraduate medical instruction in allergy. Postgraduate training sponsored by our national allergy societies affords internists an excellent opportunity to advance their knowledge of clinical allergy.     

The Practical Application of Narrative Medicine at Mayo Clinic: Imagining the Scaffold of a Worthy House

American health care institutions increasingly recognize narrative medicine as a means to developing quality patient care. More commonly applied in health care professional development settings, narrative medicine is less overtly employed with patient populations. In this article, we describe the application of various narrative practices in the patient care and medical education programs of a major health care center in Minnesota. We discuss the impact of these programs on their participants in relation to the evidence based in current scholarship. Further, we examine narrative externalization of illness in Katherine Butler Hathaway’s disability memoir “The Little Locksmith,” a text which implicates the work of metaphor-making as a transformative step in healing. While several reports demonstrate that patients can find creative writing during times of illness to be therapeutic, there are many for whom the practice is problematic or unattractive, obstacles to practice implementation that the authors discuss. However, based on the experience of our institution, for health care institutions seeking to build a legacy of leadership in empathic patient care, narrative—employed in mentoring physicians in training and in establishing strong, dialogic relationships with patients and colleagues—should serve as a central strategy, or scaffold.     

Licorice in Leviathan: The medicalization of care for the Japanese elderly

Attitudes towards, and treatment of the elderly in Japan are discussed and the medicalization of their health care is examined. It is suggested that the ready availability of medical care will not eliminate the major problems that the elderly experience. The process by which traditional medicine has been incorporated systematically into the socialized health care system and its use in connection with the problems of elderly patients is documented. Modifications in the application of herbal medicine made by biomedical practitioners have been linked to cases of iatrogenesis in the elderly. In conclusion, the social construction of both traditional East Asian medicine and biomedicine in Japan is briefly examined; in both systems the somatic aspects of the problems of the elderly are emphasized while the social dimensions remain largely unquestioned.     

The Oslerian Tradition and Changing Medical Education: A Reappraisal

Although only 21 of Sir William Osler''s 45 years in academic medicine were spent in US medical schools (1884 to 1905), he played a major role in shaping modern medical education in this country. The integration of scholarship with patient care, together with the science and art of medicine, was central to Osler''s teaching and writing throughout his career. A classic generalist and a charismatic clinical teacher, he taught by example and was as concerned with the ideals of medicine as with its science and knowledge.Many changes have reshaped the content, process and concerns of American medical education since Osler''s time. Subspecialization and balkanization of medical education and practice have become dominant. Many of the important issues in medicine today do not fit neatly into the domain of any of the established specialties or medical organizations. There is now an urgent need to promote generalist attitudes in medicine, and the Oslerian tradition has much to offer in approaching today''s problems in medical education and practice.     

整合医学在急诊科危重病救治中的应用

整合医学是医学发展的必然方向和必由之路,强调将医学各领域最先进的理论知识和临床各专科最有效的实践经验进行有机整合,是更加符合人体健康和疾病治疗的新医学体系。急诊科危重病员往往同时存在多脏器功能障碍,救治中应运用整体观、整合观和医学观的原则,切实解决临床实践中遇到的问题。当前,有必要在组织管理层面上借力整合医学推动急诊医学的建设与发展。     

Teaching Medical Ethics to Meet the Realities of a Changing Health Care System

The changing context of medical practice—bureaucratic, political, or economic—demands that doctors have the knowledge and skills to face these new realities. Such changes impose obstacles on doctors delivering ethical care to vulnerable patient populations. Modern medical ethics education requires a focus upon the knowledge and skills necessary to close the gap between the theory and practice of ethical care. Physicians and doctors-in-training must learn to be morally sensitive to ethical dilemmas on the wards, learn how to make professionally grounded decisions with their patients and other medical providers, and develop the leadership, dedication, and courage to fulfill ethical values in the face of disincentives and bureaucratic challenges. A new core focus of medical ethics education must turn to learning how to put ethics into practice by teaching physicians to realistically negotiate the new institutional maze of 21st-century medicine.     

Preregistration house officers in the four Thames regions: II. Comparison of education and workload in teaching and non-teaching hospitals.

OBJECTIVE--To detect differences in the education and workload of preregistration house officers working in teaching and non-teaching hospitals. DESIGN--A postal questionnaire. SETTING--Teaching and non-teaching hospitals in the four Thames regions. PARTICIPANTS--1064 Preregistration house officers. RESULTS--Response rate was 61% for teaching hospitals and 73% for non-teaching hospitals. House officers in teaching hospitals had significantly fewer inpatients under their care (house physicians 16.9 v 22.9, house surgeons 17.9 v 20.3) and admitted fewer emergency patients per week (house physicians 7.7 v 12.7, house surgeons 6.5 v 9.8). More house officers in teaching hospitals reported that they had too few patients to provide adequate clinical experience. More of their time was consumed by administrative activities devoid of educational value. CONCLUSION--Preregistration house officer posts at teaching hospitals provide less clinical activity and are perceived as less educationally satisfactory by their holders than those elsewhere.     

Advance directives: the views of health care professionals.

OBJECTIVES: This study examined the views and experiences of 20 physicians and 20 nurses at a major Canadian teaching hospital regarding the use of advance directives in clinical care. DESIGN: The participants were purposively drawn from four clinical specialties: family and community medicine, oncology, intensive care and geriatrics. Detailed interviews were conducted in person. Content analysis was used to code the data, which were further analysed with both quantitative and qualitative techniques. MAIN RESULTS: Thirty-nine of the 40 participants favoured the use of advance directives in clinical care; physicians had somewhat less positive attitudes than nurses toward such directives. Advance directives were thought by participants to be helpful in resolving disagreements between patients and their families about treatment options; in making patients more comfortable, both physically and psychologically, during the process of dying; and in opening up communication and trust among patients, their families and health care professionals. Concerns about the use of advance directives focused on the lack of clarity in some patients'' instructions, the absence of legal status for directives, the possible interference with a practitioner''s clinical judgement, the adequacy and appropriateness of patients'' information about their circumstances, and the type of intervention (passive or active) requested by patients. CONCLUSIONS: New regulations and legislation are making the use of advance directives more widespread. Health care professionals should participate in the development and implementation of these directives. Continuing professional education is essential in this regard.     

Learning to deal with drug-dependent patients: one physician's reflections.

Physicians with a contemporary education may not be adequately trained to deal effectively with drug-dependent patients. This paper details the problems that one physician encountered with such individuals in his practice. A retraining program was set up in which he received basic education in drug dependence and became involved in individual counselling with drug abusers and in research studies on alcoholism and drug abuse. Physicians must exercise caution when prescribing medications that are potentially addictive. They must have a responsible attitude in their care of drug-dependent patients. The assessment and treatment of such patients should be carried out only by a multidisciplinary team of health care professionals. These principles are best inculcated by the proper exposure of medical students to substance-abuse problems and by the availability of appropriate courses and studies in this area to practising physicians.     

Emergency physicians and sexual involvement with patients: an Ontario survey

OBJECTIVE: To describe Ontario emergency physicians'' knowledge of colleagues'' sexual involvement with patients and former patients, their own personal experience of such involvement, and their attitudes toward postvisit relationships. DESIGN: Mailed survey. SETTING: Ontario. PARTICIPANTS: Emergency physicians practising in Ontario. RESULTS: Of 974 eligible mailed surveys, 599 (61.5%) were returned. Of these respondents, 52 (8.7%) reported being aware of a colleague in emergency practice who had been sexually involved with a patient or former patient. When describing their own behaviour, 37 respondents (6.2%) reported sexual involvement with a former patient. However, of this group, only 9 (25.0%) had met the patient in an emergency department. Thus, of the total number of respondents, only 1.5% (9/599) reported sexual involvement arising out of an emergency department visit. Most respondents (82.4%) agreed that it is inappropriate behaviour to ask a patient for a date after an emergency assessment and before the patient''s departure, and 66.4% felt that it is inappropriate to contact the patient after discharge. However, only 10.6% believed it to be unacceptable to request a social meeting after encountering a patient previously cared for in the emergency department in a nonprofessional setting. Most respondents (96.5%) did not believe that sexual involvement could ever be therapeutic for the patient. However, only 66% felt that it was always an abuse of power and 62.4% supported zero tolerance of all sexual involvement between physicians and patients. CONCLUSIONS: Vague regulatory guidelines currently in place have failed to dispel confusion regarding what is acceptable social behaviour for physicians providing emergency care. Our results support the need for clarification, and suggest a basis for guidelines that would be acceptable to the emergency medical community: that an emergency visit should not form the basis for the initiation of personal or sexual relationships, yet neither should it preclude their development in nonmedical settings.