Hoffman Kimberly G, Donaldson Joe F
Department of Internal Medicine, University of Missouri-Columbia, MA 213 Medical Sciences Building, Columbia, MO 65211, USA.
Med Educ. 2004 Apr;38(4):448-54. doi: 10.1046/j.1365-2923.2004.01799.x.
Academic medical centres face major challenges, and finding creative, effective strategies to support patient care and teaching are critical for survival. At the centre of these challenges is clinical teaching.
To characterise how context influences clinical teaching.
Multiple embedded case-study design analysed 3 internal medicine in-patient teams. Direct observations, interviews and documents were data sources. Triangulated data, audit trails and member checks enhanced trustworthiness.
Three tensions influenced clinical teaching: 1, patient census; 2, time sensitivity of the context; and 3, the multiple and conflicting commitments of participants. Patient census exhibited the greatest influence and was the catalyst for teaching, learning, and the allocation of total time. Time functioned as an important element influencing the pace of action, reflective and interpretative cognitive processes of the team, time available for action, and the general fatigue of the team. Conflicts among the multiple roles of ward team members disrupted individual and team teaching and learning.
Clinical teaching is an open system influenced by multiple forces. Learning, teaching and patient care were very closely coupled, and learning knowledge and using knowledge were parts of the same process within the clinical context.
学术医疗中心面临重大挑战，寻找创新、有效的策略以支持患者护理和教学对其生存至关重要。这些挑战的核心是临床教学。
描述背景如何影响临床教学。
采用多重嵌入式案例研究设计，分析了3个内科住院团队。直接观察、访谈和文件为数据来源。三角验证数据、审计线索和成员核对增强了可信度。
三种矛盾影响了临床教学：1. 患者数量；2. 背景的时间敏感性；3. 参与者的多重且相互冲突的职责。患者数量产生的影响最大，是教学、学习及总时间分配的催化剂。时间是影响行动节奏、团队反思和解释性认知过程、可用于行动时间以及团队总体疲劳程度的重要因素。病房团队成员多重角色间的冲突扰乱了个人和团队的教学与学习。
临床教学是一个受多种力量影响的开放系统。学习、教学和患者护理紧密相连，在临床背景下，学习知识和运用知识是同一过程的组成部分。
