【作者】 张莹；

【导师】 梅松丽；

【作者基本信息】 吉林大学 ， 社会医学与卫生事业管理， 2017， 博士

【摘要】 现代医学取得了辉煌的成就,但也出现了一些严重问题,突出表现在卫生领域的差异和不公平、过度医疗引发的医患关系紧张、疾病谱的改变导致单纯生物医学困境、环境与行为风险不断增加,医疗系统正变得越来越复杂。遗憾的是现代医学教育未能跟上现代医学发展的步伐,培养出来的毕业生存在明显缺陷,医学生的临床胜任能力与病人和人群需求不相匹配。学科间团队合作能力欠缺,纯生物医学模式诊疗,临床思维层次不足等。单纯生物医学模式已经不能完全适应现代医学的快速发展,这是新世纪医学卫生人才培养面临的新的严峻挑战。人力资源管理视域下,临床胜任力是影响医师工作绩效的最主要因素之一。所以,深刻理解当今医师临床胜任力内涵,有助于医师临床胜任力的提升,有助于和谐医患关系的建立,有助于培养未来卓越医生。本研究采用文献法、问卷法、访谈法等多种研究方法,构建医生临床胜任力模型,编制医师临床胜任力调查问卷,并对调查结果进行初步分析。进而,开展一系列医学教育实验,对医学生临床胜任力的教育研究进行初步探索,提出医学教育改革的路向。研究问题一。研究目的:测量医师临床胜任力,提供医师临床胜任力理论发展必须的研究工具,对本研究构建的临床医师胜任力模型的有效性和实用性进行验证,了解当今医师临床胜任力状况,挖掘其中存在的问题、提出相应的解决建议。研究方法:我们基于文献分析、通过问卷调查法和德尔菲专家咨询法等定性和定量研究方法,提出了医师胜任力模型的理论建构;采用项目分析、因子分析和潜变量结构方程模型分析对抽取的医师进行施测,通过自编的问卷,以辽宁锦州,吉林长春等地的医院为抽样调查对象。采用描述性分析、t检验、方差分析、回归分析等统计方法分析调查结果。结果:形成《医师临床胜任力问卷》,该问卷共58个题项,包含职业价值观、人格特征、知识技能、决策能力4个维度。通过问卷调查,从整体上讲,临床决策胜任力发展较慢,职业价值观仍有待加强。学历层次、职称结构、年龄、参加工作时间均对临床胜任力有影响。学历越高、职称越高、资历越高的医师,临床胜任能力也越强。临床胜任力总分、人格特征、决策能力、职业价值观和知识技能胜任力变量两两显著相关。多元线性回归分析结果显示,临床医师总的临床胜任力的影响因素为年龄、职称、工作时间,人格特征的影响因素为职称,决策能力的影响因素为性别、年龄、学历,职业价值观的影响因素为年龄、行政职务,知识技能的影响因素为工作时间、行政职务、医院类别。结论:医师临床胜任力结构及实际调查对我国医师临床胜任力框架的改进以及临床胜任力的培养具有较强的指导性和现实意义。研究问题二。研究目的:通过巴林特案例小组讨论的开展,使医学生习得多角度的临床思维方式,能更深的体会自己的思想、情绪、人格对病人的影响,促进医学生的人文精神的人格特征的塑造,提高临床沟通的技巧。研究方法:采用方便抽样,选择某校临床医学专业学生68人开展实践活动,进行访谈和问卷研究。结果:参与者能从心理和社会视角观察困难的医患关系,对医患关系产生新的觉察,培养具备人文精神的人格,有效应对医患关系。结论:巴林特案例小组讨论能对成员塑造具有人文精神的人格特征产生积极影响。研究问题三。研究目的:验证形成性考核评价的反馈类型与学业水平对学生知识技能胜任力的获取的影响。研究方法:采用方便抽样,选取大四临床医学专业医学生252人,分别以优/差学业水平(2)×正/无反馈类型(2)进行分组完成实验研究,结果:形成性评价的反馈类型对终结性考核成绩影响显著(F=6.784,P<0.05),正反馈与不反馈相比,学生的成绩更高。反馈类型和学业水平的交互效应(F=6.729,P<0.05)显著,反馈类型对学差生的影响程度高于学优生。结论:在专业课程教学中开展形成性评价,反馈类型影响医学生临床知识技能胜任力的获得。研究问题四。研究目的:探讨以临床胜任力为导向,在医学生生产实习阶段开展形成性学习评价的效果。研究方法:采用方便抽样,选取临床医学专业大五生产实习学生为研究对象,采用实验组和对照组设计,实验组开展形成性评价,对照组采用传统实习方法,比较两个组Mini-CEX结构化问卷的成绩。结果:实验班结构化问卷得分显著高于对照班(P<0.001)。结论:在临床实习阶段开展形成性评价有助于学生临床胜任力的获得,学习者的职业价值观和临床决策胜任力水平显著提高。研究问题五。研究目的:当今盛行的生物医学模式难以满足临床需要,医疗环境的改善依靠教育系统的改变,传统的医学人才培养模式僵化,我们需要探索一种能胜任人群健康服务的转化式教育方法来培养医学生的临床胜任力。结果:转化式学习是参考框架有效改变的过程,以批判性反思为基本特征。基于胜任力的转化式学习是课程设计集系统性和实践性、医学技术与人文精神有机统一、以病人或人群需要为中心、紧扣医疗实践和学生临床胜任能力发展、探索适应生物心理社会医学模式的临床实践程序的转化式学习过程。基于胜任力的转化式学习的有效开展,必须开展:根据临床实践需要设置课程体系、以学生为中心的个性化教学、利用网络信息技术支持转化式学习、基于生物心理社会医学模式的临床思维教学、教师教育理念的转变。更多还原

【Abstract】 Modern medicine has made brilliant achievements,but there are some serious problems.Firstly,there aredisparities and inequities in the health field.Secondly,there are excessive medical treatments caused by the tension in the doctor-patient relationship.Thirdly,the change of disease spectrum results in biomedical dilemma.Fourthly,environment and behavior risk is increasing.The medical system is becoming more and more complex.Unfortunately,modern medical education has failed to keep pace with the pace of modern medical development.There are obvious defects in the graduates trained in this field,and the post competency of medical students does not match the needs of the patients and the population.The other defects include the lack of teamwork ability,pure biomedical model diagnosis and treatment,and the lack of clinical thinking level.Pure biomedical model is not able to adapt to the rapid development of modern medicine.These are the new and severe challenges for the training of medical talents in the new century.In the field of human resources management,competency is one of the most important factors affecting physician performance.Therefore,a profound understanding of today’s physicians’ competency is helpful to enhance the physician competency,to build a harmonious relationship between doctors and patients,and to culture future excellent doctors.This study used literature,questionnaire,and interviews methods to construct the competency model of physicians.The results of the survey were analyzed.And then,the author develops a series of education experimentsof medical students’ clinical competence,and puts forward transformation education is the direction of medical education.ResearchⅠ.OBJECTIVE: Measure physician competency.We provide the necessary research tools for the development of the physician competency theory.We validate the competency model and find the problems and put up related suggestions.METHODS: Based on the literature analysis and the qualitative and quantitative research methods such as questionnaires and Delphi methods,we put forward the theoretical construction of the physician competency model.Item analysis,factor analysis,and latent variable structural equation model analysis were tested on a random sample of physicians.Through the self-designed questionnaire,the hospitals in Liaoning,Jinzhou,Jilin,Changchun places were investigated.By the results of descriptive analysis,t test,analysis of variance,and regression analysis,we understand the current status of clinical competency.RESULTS: A total of 58 items were included in the questionnaire,including professional values,personality characteristics,knowledge skills and decision-making ability.Through questionnaire investigation,we found that the clinical competency of doctors was inconsistent.Overall,clinical decision making competencies developed slowly,and professional values need to be strengthened.Educational level,title structure,age and working time had influence on clinical competence.The higher the degree,the higher the title and the qualifications of physicians,clinical competence was also stronger.There were significant correlations among any two variances in clinical competence scores,personality characteristics,decision-making ability,occupational values and knowledge and skills competence.Multiple linear regression analysis showed that the major factors affecting the total competency were age,job title and working time.Influencing factor of personality traits was the title.Factors affecting the decision-making ability were gender,age and educational degree.Factors influencing occupation values were age and administrative duties.Factors affecting knowledge and skills were the job time,the administrative duties and the hospital type.CONCLUSION: Physician clinical competence structure and actual investigation have strong guiding and practical significance to the improvement of physician clinical competency frame and the cultivation of clinical competency.Research II.OBJECTIVE: To make medical students form a multi-angle clinical thinking through the Balint case discussion groups.Furthermore,students realize the influence of their thoughts,emotions and personality on the patients,and promote own the medical humanities characters and clinical communication skills.METHODS: A total of 68 clinical medical students were conveniently sampling selected to carry out practical activities and conduct interview and questionnaire research.RESULTS: Participants can observe the difficult doctor-patient relationship from the psychological and social angle,have a new awareness of the relationship between doctors and patients,effectively deal with the relationship between doctors and patients,and ease the doctor-patient conflict.CONCLUSION: Balint case discussion groups have a positive impact on members’ humanistic personality traits.Research III.OBJECTIVE: To verify the influence of feedback type and academic level on the acquisition of students’ knowledge and skills.METHODS: A total of 252 medical undergraduates were selected by conveniently sampling,and they were random divided with excellent/bad academic level(2)×have/no feedback type(2)of 63 students respectively.RESULTS: Thetype of feedback of the formative evaluation had a significant effect on the final examination(F = 6.784,P< 0.05).Positive feedback was higher than non-feedback.(F = 6.729,P< 0.05),and the influence of feedback types on the students who study badly was higher than that of excellent students.CONCLUSION: Formative evaluation is carried out in the professional curriculum,and the type of feedback influences medical students’ the clinical knowledge and skill competence to obtain.Research Ⅳ.OBJECTIVE: To explore the effect of formative learning evaluation in clinical practice stage of medical students.METHODS:By conveniently sampling,the clinical medical students grade fifth in internship as the research object,the experimental group and control group design,experimental group to carry out formative evaluation,the control group used the traditional method of practice,comparing the two groups of Mini-CEX structured questionnaire scores.RESULTS: Scores of an experimental class participating in formative assessment in the practicum process were significantly higher than those of the control group(P < 0.001).Conclusion: The formative evaluation in the clinical practice stage will help students to obtain the clinical competence,and the learners’ professional values and clinical decision-making competencies are significantly improved.Research Ⅴ.OBJECTIVE: The current biomedical model is difficult to meet the clinical needs.The improvement of the medical environment depends on the change of the educational system.It is rigid on the traditional training mode of medical talants.We need to explore a transformative education pathway to cultivate medical students’ competencies.RESULTS: Transformative learning is a process of effective change of reference frame,which is characterized by critical reflection.Competency-based transformational learning is a transformational learning process that integrates systematic and practical curriculum design,integrates medical technology and humanistic spirit,focuses on the needs of patients or people,closely aligns medical practice with students’ competency development,and explore the clinical practice of adapting to the psychosocial medical model.CONCLUSION: Based on the effective development of competency-based learning,we must carry out: according to clinical practice needs to set the curriculum system,student-centered personalized teaching,the use of network information technology to support transformational learning,clinical thinking teaching based on biopsychosocial model,change in the concept of teaching.更多还原