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

Leon Piterman，黃文靜(譯)，楊 輝(譯)

·世界全科醫(yī)學工作瞭望·

【編者按】 澳大利亞的全科醫(yī)生具有行業(yè)自律性，體現在其自行制定行業(yè)標準、自主進行資質考核及自主執(zhí)業(yè)等方面，也體現在《The Medical Republic》這一共享平臺上。Leon Piterman是醫(yī)學學士，醫(yī)學博士，教育學碩士，英國醫(yī)生學會會員，澳大利亞全科醫(yī)生學會會員，Monash University副校長、全科醫(yī)學教授，從事全科醫(yī)學臨床服務近40年；研究興趣為慢性病管理、心理健康、醫(yī)學教育；曾獲澳大利亞勛章，醫(yī)學部醫(yī)學教育獎，澳大利亞全科醫(yī)生學會研究獎，香港全科醫(yī)生學會研究獎等；獲多項澳大利亞衛(wèi)生和醫(yī)學研究理事會等大型研究項目，發(fā)表科學文章和著作章節(jié)120余篇，是《全科醫(yī)學中的精神病學》合作著者。Piterman教授建議我國的全科醫(yī)生應培養(yǎng)“共和”思想，以為全科醫(yī)學領域提供更多的平等交流機會。目前Piterman教授定期為《The Medical Republic》撰寫文章，本刊深受“醫(yī)學共和”思想的啟發(fā)，特邀本刊編委Monash University楊輝教授對Piterman教授的文章進行編譯，并進行連載刊登！本期Piterman教授為我們講述了在臨床帶教中從實習醫(yī)學生處學到新知識的經歷，并認為臨床帶教教師和實習醫(yī)學生之間可以互相影響、互相促進，教亦學，學亦教，教學相長，相得益彰！

1.3168 Monash University,Melbourne,Australia

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

注：本文首次刊登于《The Medical Republic》

《The Medical Republic》案例分享
——亦教亦學：醫(yī)學生可以讓全科醫(yī)生學到什么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

致力于獲取新的知識，有時是一種謙遜品格，但有時也可能是一場徹頭徹尾的尷尬。

我大學時候的座右銘是“Ancora imparo”，翻譯成中文就是“我仍在學習中”。這條座右銘告訴我們，學習是一件畢生的事。其不僅代表了大學畢業(yè)后的持續(xù)職業(yè)發(fā)展，也代表了要不斷學習多樣化的新技能，包括運動、音樂、藝術及其他領域。雖然這條座右銘非常明確地強調了我們要成為學習者，但卻并沒有告訴我們應該從哪里去學習、一個人的學習偏好是什么、教師應該具備什么樣的天性和素質。

我是一位終生學習者，也是一位長期教育工作者。和許多全科醫(yī)生一樣，我很看重利用各種各樣的機會去獲取新的知識和技能，比如閱讀期刊、互聯網搜索、參加學術會議和研討會、參加網上論壇、與有經驗的同事溝通、閱讀專家報告、與專家討論具體案例和觀點等。為了能更深刻地領悟學到的知識，我需要將其與臨床實踐結合起來，最強大、最有用的學習經驗，就是把學習焦點集中在自己曾經嘗試解決的臨床問題上。

多年來，我非常有幸能在全科醫(yī)學診所給醫(yī)學生帶教。我總是在想，這個教學過程能讓帶教教師學到什么呢？來全科醫(yī)學診所實習的醫(yī)學生，是帶著他們在大學課堂上獲得的新知識來的，他們嘗試著將這些新知識應用在全科醫(yī)學診療過程中。我把這些醫(yī)學生看做新的學習資源，但向這些年輕的準醫(yī)生學習，可能是展現了我謙遜的品格，但也可能會是一場徹頭徹尾的尷尬。

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，也在通過飲食控制2型糖尿病。她有間歇性頸痛和頭痛，頸部活動受限，X線片證實為嚴重頸椎病。我將她的頭痛歸因為頸椎的退行性病變。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)，擔心自己的疼痛會是由遺傳引起的。我否認了她的猜想，禮貌地告訴她，目前為止佩吉特病被認為是不遺傳的。

幾個月后，我在診所給醫(yī)學生帶教，正好弗洛倫斯來就診。在帶教過程中遇到長期就診的老患者是經常出現的情況，于是我讓醫(yī)學生們對弗洛倫斯進行病史采集和頭頸部檢查。很快，醫(yī)學生們給出了報告，認為弗洛倫斯可能患有佩吉特病。我詢問他們給出這個診斷的原因，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，檢查結果證實了醫(yī)學生們的診斷。我很自然地對醫(yī)學生們表示了贊賞，并向弗洛倫斯道歉，然后將弗洛倫斯轉診給適合的?？漆t(yī)生。我感到內疚和羞愧，但弗洛倫斯之后仍會來診所找我就診，這讓我感到很安慰。

那么，在這個過程中我學到了什么呢？首先，我需要認真聆聽患者的擔心，然后積極應對，而不是單純否定。其次，我意識到在臨床上解決內分泌問題時，應注意患者外觀上的微妙變化。臨床上一些習以為常的表現，容易受到醫(yī)生的忽視，這也常是誤診的原因之一。解決這個問題的方法很簡單，明智的醫(yī)生會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)學生)來給出一個診斷。像我這樣經驗豐富的全科醫(yī)生，每天會接診很多患者，對患者外觀上的細微變化敏感度較低，而年輕的醫(yī)生和醫(yī)學生會很容易就注意到這一點。

上述故事發(fā)生一段時間之后，年輕媽媽貝姬帶著她4個月大的男嬰杰米來就診。杰米有明確的遺傳性過敏性皮炎家族史，典型表現為濕疹，貝姬給杰米用了保濕霜但效果甚微。在前次就診時，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題。我的醫(yī)學生對孩子進行了檢查，然后問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。這個建議讓我很震驚，貝姬也感到很驚訝。醫(yī)學生說：“是的，教授，用漂白粉。因為葡萄球菌會加重濕疹，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個星期后，貝姬抱著杰米來診所復診，杰米的皮膚癥狀明顯改善！

我們是教師，我們要給醫(yī)學生帶教，但教師從某種角度而言也是學生。我喜歡給實習醫(yī)學生帶教，不僅是為了感受教師的光榮，也是為了從他們那里學到更多知識。我越來越相信，教亦學，學亦教，教學相長！

譯者注：(1)Ancora imparo：我仍在學習中，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，表現為皮內或皮下腺體癌，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個月；然后3次/周，持續(xù)1個月；然后1次/周，持續(xù)1個月。如濕疹復發(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《中國全科醫(yī)學》。

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：醫(yī)學生可以讓全科醫(yī)生學到什么[J].黃文靜，楊輝，譯.中國全科醫(yī)學，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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