14-美国全科住院医师的一天.ppt

A DAY IN THE LIFE OF A FAMILY PRACTICE RESIDENT家庭医学住院医生的一天生活家庭医学住院医生的一天生活Terminology专业名词®Resident: a “post-graduate” undergoing a period of advanced training, gaining supervised practical experience in a medical specialty that normally follows graduation from medical school and licensing to practice medicine ®住院医生：从医学院毕业并取得行医执照后在一段时间内在督导下接受某个医学专业的进一步培训以获得临床经验®Intern: a first-year resident实习医生：第一年住院医生®Education in the US:美国的教育®High school, lasting 4 years to age 18 高中，4年时间，直到18岁®University, lasting 4 years to age 22 大学，4年时间，直到22岁®Medical school, lasting 4 years to age 26 医学院，4年时间，直到26岁®Family Medicine Residency, lasting 3 years to age 29 家庭医学住院医生，3年时间，直到29岁Three-year program3年计划®Year One Rotations 第一年轮转®Family Medicine Inservice (4 months)家庭医学病房（4个月）®Pediatrics (2 months)儿科（2个月）®Obstetrics (2 months)产科（2个月）®Emergency Room (1 month)急诊室（1个月）®Surgery (1 month)外科（1个月）®Community Medicine (1 month)社区医学（1个月）®Community resources: 社区资源lCrisis Pregnancy 高危妊娠lHospice 临终关怀lPT/OT康复医学Three-year program3年计划®Year 2-3 Progressive Responsibility on the Family Medicine Inservice在家庭医学病房第2-3年责任递增®1month rotations:一个月轮转®Second-year resident in ICU and OB supervising interns第二年住院医生在ICU和产科监督第一年住院医生®Third-year Senior supervising second-year and first-year residents第三年住院医生监督第二年和第一年住院医生®Night Call 夜间呼叫lSame as On-Call team responsibilities与待命人员职责一样lOnly one resident in-house仅一个住院医生在医院值班lHeight of progressive autonomy增加自主程度lIn-house attending physician 在医院值班的主诊医师Three-year program3年计划®Year 2-3 Rotations: 第2-3年轮转®one-on-one with attendings与主诊医师一对一®both inpatient and outpatient住院病人和门诊病人®1 month 1个月®Critical Care (ICU/Pulmonology)急危重症医学（ICU / 肺病）®Gynecology妇科®Surgery外科®Gastroenterology胃肠病科®Cardiology心脏病科®Behavioral Medicine行为医学科Three-year program3年计划®Longer Rotations:更长的轮转®Obstetrics (2 months)产科（2个月）®Orthopedics (1.5 months)骨科（1.5个月）Three-year program3年计划®Shorter rotations (1/2 month)较短的轮转（半个月）®Neurology神经科®Ophthalmology眼科®Dermatology皮肤科®Ear/Nose/Throat耳鼻喉科®Urology泌尿科®Sports Medicine运动医学科®Practice Management 医疗管理Three-year program3年计划®Year 2-3 Electives (3 months total) 第2-3年选修（共3个月）®Foreign medical work (with board certified teaching physician)海外医疗工作（与通过资格认证的医师一起工作）®Rheumatology风湿病科®Nephrology/Renal肾脏科®Infectious Disease感染病®Cardiovascular Surgery心血管外科®Anesthesia麻醉科®Procedural Training 操作训练FIRST-YEAR RESIDENT (THE INTERN) 住院医生第一年（实习医生）住院医生第一年（实习医生）®4:30 AM: YOU AWAKEN 4:30 AM: 醒来®5:30 AM: YOU ARRIVE AT THE HOSPITAL 5:30 AM: 到达医院®6 PATIENTS ON THE WARD, 1 IN THE INTENSIVE CARE UNIT TO SEE 病房中有6个病人，1个病人在重症监护室需要去看®YOU MUST WRITE PROGRESS NOTES AND ORDERS FOR EACH PATIENT 你必须写下每个病人的病情进展和医嘱SOAP note SOAP记录法®S: Subjective S:主观的®O: Objective O:客观的®Vital signs, ventilator settings 生命体征，呼吸机设置®Physical Exam体格检查®Labs实验室检查®Studies研究资料®A: Assessment (diagnoses, progress) A: 评估（诊断，进展）®P: Plan for each assessment P: 对每个评估的计划Checking labs, studies, monitors核查实验室结果、文献、监护Checking with ICU nurses for overnight updates向ICU护士了解前夜的病情变化Checking on your patients (pediatric/adult, medicine/surgery, ICU)检查病人（儿童、成人、内科、外科、ICU）Reviewing specialist recommendations回顾专科医生的建议CODE BLUE!!!紧急呼叫®6:45 AM: ONE OF YOUR PATIENTS BECOMES A CODE BLUE 6:45 AM你的一个病人病情危重®YOU RUN THE CODE AS FIRST RESPONDER; RESPIRATORY THERAPY, ANESTHESIA, AND CODE TEAM ASSIST 你作为第一急救者启动急救；呼吸治疗，麻醉，急救团队帮助®PATIENT REVIVES 病人复苏®TRANSFERRED TO THE INTENSIVE CARE UNIT 转移到重症监护室CODE BLUE!!!紧急呼叫®Advanced Cardiac Life Support (ACLS)高级心脏生命支持®Pediatric Life Support (PALS)小儿生命支持®Advanced Life Support for Obstetrics (ALSO)高级产科生命支持Algorithms 流程图Team Approach团队方法®7:45 AM: YOU ARRIVE AT THE REPORT ROOM FOR ROUNDS 7:45 AM: 你到达医生办公室开始查房®YOU UPDATE YOUR SUPERVISING SENIOR RESIDENT ON YOUR PATIENTS 你向指导你的高级住院医生汇报病人的新情况Team团队 -Senior 3rd-year resident 高年级（3年级）住院医生§Oversees whole service 负责监督整个病房的医疗服务-Senior 2nd-year resident 高年级（2年级）住院医生§Oversees Intensive Care and Obstetrics 监督重症监护室和产房 -Interns/1st-year residents (4) 实习医生/1年级住院医生§Report on the patients they saw in the morning (SOAP) 早晨汇报所见的病人情况（SOAP）*Senior residents help to refine interns’ assessment and plan 高级住院医生帮助改进实习医生的评估和诊疗计划®8:00 AM: YOU AND YOUR RESIDENT TEAM SET ASIDE TIME TO 8:00 AM: 你和你的住院医生团队留出时间：®THANK GOD FOR HEALING感谢神的医治®TO PRAY FOR WISDOM祈求智慧®TO REFLECT THAT HE IS IN CONTROL 思想祂在掌握®TO ACKNOWLEDGE THAT ALL GOOD THINGS COME FROM HIM, INCLUDING MEDICINE 承认所有的好事情都来自于祂，包括医学。

®8:30 AM: Residents read an up-to-date article regarding one medical problem per night and discuss with each other, led by seniors 8:30 AM: 住院医生每晚读一篇与医学问题相关的文章，然后在高年级住院医生领导下，与大家讨论®Basics基础®Signs/Symptoms体征/症状®Etiology病因®Diagnosis (Differential, Work-up)诊断（鉴别诊断，实验室检查）®Treatment治疗®Medications用药®9:00 AM: YOUR ATTENDING PHYSICIAN ARRIVES 你的主诊医师到达®THE TEAM QUICKLY UPDATES HIM ON THE STATUS OF THE PATIENTS团队快速向他汇报病人的病情进展®THE ATTENDING PHYSICIAN, SENIOR RESIDENT, AND INTERNS ROUND ON PATIENTS 主诊医师、高年级住院医生和实习医生巡查病人Attending Rounds主诊医师查房®9:30 AM: Go to patients’ bedside and see patients with attendings, especially: 9:30 AM: 与主诊医师去病人床旁看病人，尤其是：®new patients 新病人®patients with classic findings有典型表现的病人®Patients with atypical findings不典型表现的病人®Discuss together一起讨论®Inpatient Pharmacist住院部药师®Checks drug interactions检查药物相互作用®Recommends treatment推荐治疗Rounds查房Intern reporting to Attending实习医生向主诊医师汇报Intern presenting x-ray on electronic imaging hospital program实习医生在医院电子成像系统上描述X光片所见®11:00AM: YOU AND THE OTHER 3 INTERNS RESUME CARING FOR YOUR INDIVIDUAL PATIENTS 11:00AM:你和其他的3名实习医生继续看顾自己的病人®DISCHARGING 2 PATIENTS, AND CHECKING ONCE AGAIN ON YOUR MORE CRITICAL ONES 为两个患者办理出院，然后再次查看病重的患者®12:00PM: YOU RETURN TO THE REPORT ROOM FOR TEACHING ROUNDS 12:00PM:你回到医生办公室接受教学查房Noon Teaching午间教学®Case presentation by interns to team实习医生向团队做病例汇报®Special patients特殊病人®Guest Speakers客座讲员®Review Questions回顾问题®Grand Rounds大查房®Special topics特别主题®Newest treatments/developments最新治疗/进展®New policies新政策®Case presentations病例汇报®1:00 PM: YOU CHECK-OUT YOUR PATIENTS TO YOUR SENIOR RESIDENTS BEFORE LEAVING FOR CLINIC 1:00 PM: 向高年级住院医生交班，然后离开去诊所®1:30 PM: YOU ARRIVE AT CLINIC 1:30 PM: 到达诊所 ALREADY, THREE PATIENTS ARE WAITING FOR YOU 已经有3个患者在等你了®A PATIENT WITH GASTROESOPHAGEAL REFLUX DISEASE 一个患者有胃食道返流病®AN EXERCISE TREADMILL TEST 一个要做脚踏车运动试验®A CIRCUMCISION 一个包皮环切术Clinic, where residents and attendings practice medicine together.诊所，是住院医生和主诊医师共同行医的地方。

You discuss each case with your preceptor. 你同督导老师讨论每个病例Clinic Training 门诊训练®Continuity clinics 持续性照顾的门诊®First Year: 1-2 half-day clinics/week第一年：每周1-2个半天的诊所工作®36 patients per half day每个半天看3-6个病人®140 patient visits 共看140个病人®Second Year: 2-3 half-days 第二年：2-3个半天®710 patients per half day每个半天看7-10个病人®500 patient visits 共看500个病人®Third Year: 3-4 half-days 第三年：3-4个半天®1115 patients per half day 每个半天看11-15个病人®1000 patient visits 共看1000个病人YOU SYNCHRONIZE YOUR POCKET PC 将你的掌上电脑同步化Personal Digital Assistant个人数字助理 (PDA)®Data base meta-analysis: Up-to-date 数据库数据库meta分析：更新分析：更新®Internet网络®Books: dictionaries, texts书籍：字典，课本®Tools: OB wheel, algorithms 工具：产科轮表；流程图®Most updated drug interface: epocrates 最新更新的药物界面： epocrateslDiagnosis诊断lTherapy治疗lSymtoms症状lLabs实验室检查lMed Calculations医学计算lTables表格Use of Electronic Medical Records (EMR), initiated in the U.S. by Family Medicine Physicians使用由家庭医生引入美国的医学电子档案Air panels to use within patient rooms for all documentation在病房里可以无线连接所有文件®5:00 PM: FINISHED WITH CLINIC, YOU RETURN TO THE HOSPITAL FOR CALL 5:00 PM: 完成诊所工作，回到医院值班®5:30 PM: YOU RETURN TO THE HOSPITAL AND CHECK OUT WITH YOUR COLLEAGUES 5:30 PM: 你回到医院跟同事接班®6:00PM: YOU ARE PAGED TO SEE TWO PATIENTS IN THE EMERGENCY ROOM 6:00PM: 你被叫去看两个急诊室里的病人Admissions收入院®Throughout the day贯穿整天®Emergency Room physician stabilizes patient and transfers patient to the family medicine team急诊医生稳定病情后就将病人转给全科医生团队®Residents review ER events and patient’s work-up 住院医生回顾急诊情况和病人的检查结果®Call for old records调出以往的记录®Full work-up: History and Physical整体情况：病史和查体®Intern sees patient first, unless critical (senior resident would go with intern then)若非紧急情况，实习医生先看病人（若紧急则高年级住院医生一起去）History & Physical病史和查体®Chief Complaint主诉®History of Present Illness现病史®Past Medical / Surgical History既往医疗/手术史®Allergies / Medications过敏史/用药史®Review of Systems系统回顾®Social History: 社会史®Tobacco/alcohol/drugs烟/酒/药物®Family situation家庭史®Sexual history性生活史®Spiritual history精神病史History & Physical病史和查体®Vital Signs生命体征®Physical Exam体格检查®Labs实验室检查®Studies研究®Assessment病情评估®Plan诊疗计划®Discuss with senior, fine tune plan与高年级住院医生讨论，调整诊疗计划®Intern and senior discuss with attending physician 实习医生和高年级住院医生与主诊医师讨论®7:30 PM: YOU FINISH WRITING ORDERS FOR TRANSFER TO THE INTENSIVE CARE UNIT ON YOUR NEW PATIENT WITH DIABETIC KETOACIDOSIS 7:30 PM:你写完了将新接收的糖尿病酮症酸中毒的患者转到重症监护室的医嘱®8:00 PM: YOU AND YOUR SENIOR ARE FINISHING IN THE EMERGENCY ROOM WHEN YOU ARE PAGED TO A DELIVERY 8:00 PM: 你和你的高年资住院医生完成了急诊室里的工作，这时你被叫去接生®HEART TONES DECLINE, REQUIRING VACUUM ASSISTANCE 心音减弱，需要吸引器助产®YOU REPAIR A SECOND DEGREE PERINEAL LACERATION 你修补会阴二度撕裂伤口®9:30 PM: YOU’RE PAGED TO THE NURSERY TO SEE THE NEWBORN YOU JUST DELIVERED 9:30 PM: 你被叫到婴儿室去探视你刚刚接生的新生儿®10:15 PM: ANOTHER PATIENT WITH ALCOHOL WITHDRAWAL SEIZURES AWAITS YOU IN THE EMERGENCY ROOM 10:15 PM: 另一个有着酒精戒断性癫痫发作的患者在急诊室等着你®11:00 pm: FINALLY YOU’RE DONE – TIME TO CATCH 5 HOURS OF SLEEP BEFORE STARTING YOUR DAY ALL OVER AGAIN! 11:00 pm: 终于结束了–在重新开始明天的工作前抓紧时间睡5个小时SECOND YEAR RESIDENT第二年住院医生第二年住院医生®6:30 AM: YOU AWAKEN; TODAY YOU’LL BE WORKING AT THE MATERNAL HEALTH CLINIC 6:30 AM: 醒来；今天要在孕产妇门诊工作®8:00 AM: THIRTY PATIENTS ARE WAITING TO BE SEEN 8:00 AM: 有30个患者要来看®6 ULTRASOUNDS TO DO 6有6个超声要作®ONE PATIENT IS BLEEDING 一个患者在出血®12:00 PM: FINISHED WITH PATIENTS, YOU WORK A LITTLE ON YOUR RESEARCH PROJECT 12:00 PM: 看完患者，你做一些科研课题方面的工作®12:30 PM: YOU SPEND THE AFTERNOON WITH DR. YODER, A PRIVATE GASTROENTEROLOGIST 12:30 PM:你和私人开业的胃肠病学专家Dr.YODER一起度过下午 ®6 COLONOSCOPIES, 3 UPPER ENDOSCOPIES, 1 CONSULT 6个结肠镜检查，3个上消化道内窥镜，一个会诊®5:00 PM: YOU RETURN TO THE CLINIC TO PICK UP THE CELL PHONE AND PAGER FOR PHONES-CALL 5:00 PM: 你回到诊所去取接急诊的和呼机®5:30 PM: DINNER WITH YOUR FAMILY IS CONSTANTLY INTERRUPTED BY PHONE CALLS FROM PATIENTS WITH CONCERNS 5:30 PM: 同家人进餐，但不时被来自询问病情的病人的打断®EAR INFECTION 耳部感染®CHRONIC BACK PAIN 慢性背痛®ANXIETY ATTACK 焦虑发作®9:00 PM: YOU ARE PAGED TO INFORM YOU THAT ONE OF YOUR PRIVATE OBSTETRICAL PATIENTS IS IN LABOR 9:00 PM: 呼机响，你被告知你的一个产科病人正在临产®11:30 PM: BABY DELIVERED, PHONES-CALL OVER, YOU RETURN HOME TO A SLEEPING FAMILY 11:30 PM: 婴儿娩出，接急诊的任务完成，你回到熟睡的家人身边THIRD YEAR RESIDENT第三年住院医生第三年住院医生®6:30 AM: YOU AWAKEN; GETTING READY TO LEARN ALL MORNING FROM ORTHOPAEDIC SURGERY AND CLINIC WITH DR HOLT, A TEACHING PHYSICIAN 6:30 AM: 醒来，准备用整个上午在骨科 教学医生 DR HOLT的门诊中学习®1:00 PM: FINISHED WITH ORTHOPAEDICS, YOU DRIVE ACROSS TOWN TO START YOUR OWN FAMILY MEDICINE AFTERNOON CLINIC 1:00 PM: 骨科手术完成，你开车穿过城镇开始自己下午的全科门诊®OBSTETRICAL PATIENT 产科病人®VASECTOMY 输精管切除术®OTHER VARIED PROBLEMS: HYPERTENSION, DIABETES, SKIN CONDITIONS, UPPER RESPIRATORY INFECTIONS 其他各种问题：高血压，糖尿病，皮肤病，上呼吸道感染®4:00 PM: QUARTERLY MEETING WITH YOUR ADVISOR 4:00 PM: 同你的指导教授的季度会议®REVIEWS YOUR PROGRESS AND EVALUATIONS 回顾自己的进步和评估 ®INQUIRES ON YOUR JOB SEARCH 询问你找工作的情况®CHECKS ON YOUR STUDY PLAN FOR PASSING THE FAMILY PRACTICE BOARD CERTIFICATION EXAM IN JULY 检查你为通过7月份的家 庭医生资格认证考试的学习计划®6:00 PM: YOU VOLUNTEER YOUR TIME AT THE MOBILE CLINIC FOR INDIGENT NON-PAYING PATIENTS 6:00 PM: 你志愿去移动诊所为贫穷患者义诊®20 PATIENTS ARE WAITING 20个患者在等着你®ONE PATIENT ARRIVES WITH PAINFUL BAKER’S CYST BEHIND HER KNEE 一个患者膝盖后方有Baker’s囊肿伴疼痛®ANOTHER PATIENT IS AN ALCOHOLIC WANTING TO QUIT 另一个患者是想戒酒的酗酒者®9:30 PM: FINALLY FINISHED, THE MOBILE CLINIC CLOSES UP AND DRIVES OUT OF THE CHURCH PARKING LOT 9:30 PM:终于结束了，移动诊所关闭，驶出教会停车场®YOU HEAD HOME – YOUR DAY NOW DONE 你回到家，一天结束了Progressive Learning进一步学习®Building Knowledge牢固知识®Acquiring Skills获得技能®Learning and Teaching学习和教导®Becoming comfortable with the actual practice of medicine (not just didactic)越来越自信从事临床实践（不仅仅是说教）®Advancing to Autonomy, Proficiency 自主性和熟练程度增强Most Importantly…更重要的是…®LEARNING HOW TO LEARN 懂得如何去学习®LEARNING WHERE TO LOOK FOR NEEDED INFORMATION 学习何处去查找需要的信息The challenge of family medicine家庭医学的挑战®Generalist: know something about everything通才：知道每个问题的一部分®Continuity care持续性照顾®Care for the whole person全人的照顾®Care for the entire family整个家庭的照顾Challenging but ever exciting career!有挑战性但永远令人兴奋的职业！。