Leon Piterman，黃文靜(譯)，楊 輝(譯)

·世界全科醫(yī)學(xué)工作瞭望·

【編者按】 澳大利亞的全科醫(yī)生具有行業(yè)自律性，體現(xiàn)在其自行制定行業(yè)標(biāo)準(zhǔn)、自主進(jìn)行資質(zhì)考核及自主執(zhí)業(yè)等方面，也體現(xiàn)在《The Medical Republic》這一共享平臺(tái)上。Leon Piterman是醫(yī)學(xué)學(xué)士，醫(yī)學(xué)博士，教育學(xué)碩士，英國(guó)醫(yī)生學(xué)會(huì)會(huì)員，澳大利亞全科醫(yī)生學(xué)會(huì)會(huì)員，Monash University副校長(zhǎng)、全科醫(yī)學(xué)教授，從事全科醫(yī)學(xué)臨床服務(wù)近40年；研究興趣為慢性病管理、心理健康、醫(yī)學(xué)教育；曾獲澳大利亞勛章，醫(yī)學(xué)部醫(yī)學(xué)教育獎(jiǎng)，澳大利亞全科醫(yī)生學(xué)會(huì)研究獎(jiǎng)，香港全科醫(yī)生學(xué)會(huì)研究獎(jiǎng)等；獲多項(xiàng)澳大利亞衛(wèi)生和醫(yī)學(xué)研究理事會(huì)等大型研究項(xiàng)目，發(fā)表科學(xué)文章和著作章節(jié)120余篇，是《全科醫(yī)學(xué)中的精神病學(xué)》合作著者。Piterman教授建議我國(guó)的全科醫(yī)生應(yīng)培養(yǎng)“共和”思想，以為全科醫(yī)學(xué)領(lǐng)域提供更多的平等交流機(jī)會(huì)。目前Piterman教授定期為《The Medical Republic》撰寫文章，本刊深受“醫(yī)學(xué)共和”思想的啟發(fā)，特邀本刊編委Monash University楊輝教授對(duì)Piterman教授的文章進(jìn)行編譯，并進(jìn)行連載刊登！本期Piterman教授為我們講述了在臨床帶教中從實(shí)習(xí)醫(yī)學(xué)生處學(xué)到新知識(shí)的經(jīng)歷，并認(rèn)為臨床帶教教師和實(shí)習(xí)醫(yī)學(xué)生之間可以互相影響、互相促進(jìn)，教亦學(xué)，學(xué)亦教，教學(xué)相長(zhǎng)，相得益彰！

1.3168 Monash University,Melbourne,Australia

2.518003 廣東省深圳市，羅湖醫(yī)院集團(tuán)黃貝嶺社區(qū)健康服務(wù)中心

注：本文首次刊登于《The Medical Republic》

《The Medical Republic》案例分享
——亦教亦學(xué)：醫(yī)學(xué)生可以讓全科醫(yī)生學(xué)到什么What Medcial Students Can Teach GPs

Leon Piterman1，黃文靜(譯)2，楊 輝(譯)1

全科醫(yī)生；教育，醫(yī)學(xué)

致力于獲取新的知識(shí)，有時(shí)是一種謙遜品格，但有時(shí)也可能是一場(chǎng)徹頭徹尾的尷尬。

我大學(xué)時(shí)候的座右銘是“Ancora imparo”，翻譯成中文就是“我仍在學(xué)習(xí)中”。這條座右銘告訴我們，學(xué)習(xí)是一件畢生的事。其不僅代表了大學(xué)畢業(yè)后的持續(xù)職業(yè)發(fā)展，也代表了要不斷學(xué)習(xí)多樣化的新技能，包括運(yùn)動(dòng)、音樂(lè)、藝術(shù)及其他領(lǐng)域。雖然這條座右銘非常明確地強(qiáng)調(diào)了我們要成為學(xué)習(xí)者，但卻并沒(méi)有告訴我們應(yīng)該從哪里去學(xué)習(xí)、一個(gè)人的學(xué)習(xí)偏好是什么、教師應(yīng)該具備什么樣的天性和素質(zhì)。

我是一位終生學(xué)習(xí)者，也是一位長(zhǎng)期教育工作者。和許多全科醫(yī)生一樣，我很看重利用各種各樣的機(jī)會(huì)去獲取新的知識(shí)和技能，比如閱讀期刊、互聯(lián)網(wǎng)搜索、參加學(xué)術(shù)會(huì)議和研討會(huì)、參加網(wǎng)上論壇、與有經(jīng)驗(yàn)的同事溝通、閱讀專家報(bào)告、與專家討論具體案例和觀點(diǎn)等。為了能更深刻地領(lǐng)悟?qū)W到的知識(shí)，我需要將其與臨床實(shí)踐結(jié)合起來(lái)，最強(qiáng)大、最有用的學(xué)習(xí)經(jīng)驗(yàn)，就是把學(xué)習(xí)焦點(diǎn)集中在自己曾經(jīng)嘗試解決的臨床問(wèn)題上。

多年來(lái)，我非常有幸能在全科醫(yī)學(xué)診所給醫(yī)學(xué)生帶教。我總是在想，這個(gè)教學(xué)過(guò)程能讓帶教教師學(xué)到什么呢？來(lái)全科醫(yī)學(xué)診所實(shí)習(xí)的醫(yī)學(xué)生，是帶著他們?cè)诖髮W(xué)課堂上獲得的新知識(shí)來(lái)的，他們嘗試著將這些新知識(shí)應(yīng)用在全科醫(yī)學(xué)診療過(guò)程中。我把這些醫(yī)學(xué)生看做新的學(xué)習(xí)資源，但向這些年輕的準(zhǔn)醫(yī)生學(xué)習(xí)，可能是展現(xiàn)了我謙遜的品格，但也可能會(huì)是一場(chǎng)徹頭徹尾的尷尬。

弗洛倫斯74歲，喪偶，一直在我所在的診所就診，我給她看診已經(jīng)10多年了。她看上去很健康，雖然目前正在接受高血壓治療，也在通過(guò)飲食控制2型糖尿病。她有間歇性頸痛和頭痛，頸部活動(dòng)受限，X線片證實(shí)為嚴(yán)重頸椎病。我將她的頭痛歸因?yàn)轭i椎的退行性病變。有一次看診，弗洛倫斯告訴我她的父親患有佩吉特病(Paget′s disease)，擔(dān)心自己的疼痛會(huì)是由遺傳引起的。我否認(rèn)了她的猜想，禮貌地告訴她，目前為止佩吉特病被認(rèn)為是不遺傳的。

幾個(gè)月后，我在診所給醫(yī)學(xué)生帶教，正好弗洛倫斯來(lái)就診。在帶教過(guò)程中遇到長(zhǎng)期就診的老患者是經(jīng)常出現(xiàn)的情況，于是我讓醫(yī)學(xué)生們對(duì)弗洛倫斯進(jìn)行病史采集和頭頸部檢查。很快，醫(yī)學(xué)生們給出了報(bào)告，認(rèn)為弗洛倫斯可能患有佩吉特病。我詢問(wèn)他們給出這個(gè)診斷的原因，他們讓我注意患者頭部的大小和形狀。他們告訴我，弗洛倫斯有一頂很昂貴的帽子，但現(xiàn)在卻戴不上了，而且她有頭痛的癥狀。我趕緊為弗洛倫斯安排了顱腦X線片檢查，檢查結(jié)果證實(shí)了醫(yī)學(xué)生們的診斷。我很自然地對(duì)醫(yī)學(xué)生們表示了贊賞，并向弗洛倫斯道歉，然后將弗洛倫斯轉(zhuǎn)診給適合的?？漆t(yī)生。我感到內(nèi)疚和羞愧，但弗洛倫斯之后仍會(huì)來(lái)診所找我就診，這讓我感到很安慰。

那么，在這個(gè)過(guò)程中我學(xué)到了什么呢？首先，我需要認(rèn)真聆聽患者的擔(dān)心，然后積極應(yīng)對(duì)，而不是單純否定。其次，我意識(shí)到在臨床上解決內(nèi)分泌問(wèn)題時(shí)，應(yīng)注意患者外觀上的微妙變化。臨床上一些習(xí)以為常的表現(xiàn)，容易受到醫(yī)生的忽視，這也常是誤診的原因之一。解決這個(gè)問(wèn)題的方法很簡(jiǎn)單，明智的醫(yī)生會(huì)采取開放和客觀的態(tài)度，讓其他醫(yī)生(如上述故事里的醫(yī)學(xué)生)來(lái)給出一個(gè)診斷。像我這樣經(jīng)驗(yàn)豐富的全科醫(yī)生，每天會(huì)接診很多患者，對(duì)患者外觀上的細(xì)微變化敏感度較低，而年輕的醫(yī)生和醫(yī)學(xué)生會(huì)很容易就注意到這一點(diǎn)。

上述故事發(fā)生一段時(shí)間之后，年輕媽媽貝姬帶著她4個(gè)月大的男嬰杰米來(lái)就診。杰米有明確的遺傳性過(guò)敏性皮炎家族史，典型表現(xiàn)為濕疹，貝姬給杰米用了保濕霜但效果甚微。在前次就診時(shí)，我曾建議貝姬使用低劑量的氫化可的松軟膏和濕敷料。治療有一定療效，但很顯然并未解決問(wèn)題。我的醫(yī)學(xué)生對(duì)孩子進(jìn)行了檢查，然后問(wèn)我是不是可以推薦貝姬使用漂白粉治療，就是每天在孩子的浴盆中加兩茶勺的漂白粉。這個(gè)建議讓我很震驚，貝姬也感到很驚訝。醫(yī)學(xué)生說(shuō)：“是的，教授，用漂白粉。因?yàn)槠咸亚蚓鷷?huì)加重濕疹，而漂白粉可以抑制皮膚上的葡萄球菌，這是墨爾本皇家兒童醫(yī)院的兒童濕疹診療指南提供的方法”。1個(gè)星期后，貝姬抱著杰米來(lái)診所復(fù)診，杰米的皮膚癥狀明顯改善！

我們是教師，我們要給醫(yī)學(xué)生帶教，但教師從某種角度而言也是學(xué)生。我喜歡給實(shí)習(xí)醫(yī)學(xué)生帶教，不僅是為了感受教師的光榮，也是為了從他們那里學(xué)到更多知識(shí)。我越來(lái)越相信，教亦學(xué)，學(xué)亦教，教學(xué)相長(zhǎng)！

譯者注：(1)Ancora imparo：我仍在學(xué)習(xí)中，這是Monash University的座右銘。(2)佩吉特病(Paget′s disease)：有兩種疾病被稱為佩吉特病，一種是乳房佩吉特病，表現(xiàn)為皮內(nèi)或皮下腺體癌，常源于乳腺管；另一種是佩吉特骨病，即畸形性骨炎、多發(fā)性骨膨大及骨質(zhì)軟化癥。(3)嬰兒濕疹的洗浴水配制：由澳大利亞墨爾本皇家兒童醫(yī)院皮膚病專家提出，具體指南為“水溫≤30 ℃，使用容量為10 L的浴盆，在洗浴水中加入鹽/漂白劑/浴油，洗浴后避免用清水沖洗，洗浴后使用清潔毛巾擦拭，每次洗浴時(shí)可蘸濕面部和頭部。在洗浴水中加入浴油(1～2瓶蓋/次)、池鹽(100 g/10 L)、漂白劑(4%，12 ml/10 L)。首先使用此配方洗浴水1次/d，持續(xù)1個(gè)月；然后3次/周，持續(xù)1個(gè)月；然后1次/周，持續(xù)1個(gè)月。如濕疹復(fù)發(fā)，則增加漂白劑配方洗浴頻率，并斷奶。

志謝：特別感謝原文出版者《The Medical Republic》同意將此文編譯后刊登于《中國(guó)全科醫(yī)學(xué)》。

A dedication to acquiring new knowledge can sometimes be humbling,and sometimes it can be downright embarrassing.

My university′s motto is "Ancora imparo",which translates as "I am still learning".

It implies that learning is a lifelong enterprise not limited to ongoing professional development on leaving university,but applying equally to learning new and diverse skills across a range of endeavours,be they sport,music,art or any other field.

While the motto quite rightly focuses on the learner,it is silent on the sources of learning,one′s learning preferences and the nature and qualities of the teacher.

As a lifelong learner,and long-time teacher,like many of my GP colleagues I value the opportunity to use a variety of sources for acquiring knowledge and skills.I read journals,go online,attend conferences and workshops,participate in webinars,talk to experienced colleagues and read and discuss reports from specialists.

To construct meaning from learning I need to contextualise new knowledge in relation to patient care.My most powerful and useful learning experiences have,therefore,centred on patient problems that I have tried to solve or to resolve.

For many years I have had the privilege of teaching medical students in my practice.I have always thought that teaching teaches.

Medical students bring newly acquired biomedical knowledge to their general practice encounters.They have added to my sources of learning,however there have been occasions when this learning experience has been humbling,at best,and embarrassing,at worst.

Florence was a 74-year-old widow who had attended our clinic for a number of years.I had looked after her for at least 10 of these years.She seemed in good health despite being treated for hypertension and type 2 diabetes controlled on diet alone.

She had a long history of intermittent neck pain and headache associated with restricted neck movement and X-ray evidence of advanced cervical spondylosis.

I attributed her headaches to the degenerative disease in her cervical spine.On one occasion she informed me that her father had suffered from Paget′s disease and wondered whether she may have inherited this,resulting in headaches.I dismissed this,politely informing her that as far as I knew there was no genetic basis to Paget′s disease.

Some months later I had medical student in the clinic during one of Florence′s visits and as was my normal practice I asked the student to take a history and in this case also examine Florence′s head and neck.The student soon reported back that she felt that Florence had florid Paget′s disease of the skull,supporting her diagnosis by alerting me to the size and shape of Florence′s head,the fact that she could no longer wear her cherished hats… and,of course,the headache.

An urgent skull X-ray confirmed the student′s diagnosis.Naturally,I heaped praise on the student,apologised to Florence and referred her to an appropriate specialist.Guilt-ridden and ashamed,I was grateful that Florence continued to attend our clinic.

So what did I learn from this encounter? Many things about myself and my interaction with patients.I needed to listen carefully about the patient′s concerns and ensure that I addressed them and didn′t dismiss them.

I realised that when it comes to endocrine conditions,where changes in appearance may be subtle,familiarity may breed misdiagnosis,and it is easier for a clever colleague with an open,unbiased approach,in this case a medical student,to make a diagnosis than it may be for a seasoned campaigner like me,who sees the patient on a regular basis and is oblivious to the subtle changes in the patient′s appearance.

Some time later I had an encounter with a young mother,Becky,and her four month-old male infant,Jamie.

There was a strong family history of atopy,including eczema.Jamie had a rash typical of eczema which Becky had been treating with moisturisers,without much response.On a previous visit I had suggested low-dose hydrocortisone ointment and wet dressings.

While this resulted in some improvement,it was clear that the problem was far from resolution.The medical student examined the baby and asked me if I had recommended bleach treatment… two teaspoons in the bath each day.

"Bleach!" I exclaimed,as I looked at the surprise on Becky′s face."Yes",the student replied,"it kills dermal staphylococcus which may exacerbate eczema.It is in the Royal Children′s Hospital guidelines for treating eczema."

Becky and Jamie returned a week later.Jamie′s skin had never looked better.

The value of having a medical student in practice was once again reinforced as was my belief that teaching teaches.

General practitioners;Education,medical

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10.3969/j.issn.1007-9572.2017.34.003

PITERMAN L.亦教亦學(xué)：醫(yī)學(xué)生可以讓全科醫(yī)生學(xué)到什么[J].黃文靜，楊輝，譯.中國(guó)全科醫(yī)學(xué)，2017，20(34)：4229-4231.[www.chinagp.net]

PITERMAN L.What medical students can teach GPs[J].HUANG W J,YANG H,translators.Chinese General Practice，2017，20(34)：4229-4231.

2017-10-08)

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