Bleakley Alan, Bligh John
Peninsula Medical School, Universities of Exeter and Plymouth, Exeter, UK.
Adv Health Sci Educ Theory Pract. 2008 Mar;13(1):89-107. doi: 10.1007/s10459-006-9028-0. Epub 2006 Oct 31.
Medical students must be prepared for working in inter-professional and multi-disciplinary clinical teams centred on a patient's care pathway. While there has been a good deal of rhetoric surrounding patient-centred medical education, there has been little attempt to conceptualise such a practice beyond the level of describing education of communication skills and empathy within a broad 'professionalism' framework. Paradoxically, while aiming to strengthen patient-student interactions, this approach tends to refocus on the role modelling of the physician, and opportunities for potentially deep collaborative working relationships between students and patients are missed. A radical overhaul of conventional doctor-led medical education may be necessary, that also challenges the orthodoxies of individualistic student-centred approaches, leading to an authentic patient-centred model that shifts the locus of learning from the relationship between doctor as educator and student to the relationship between patient and student, with expert doctor as resource. Drawing on contemporary poststructuralist theory of text and identity construction, and on innovative models of work-based learning, the potential quality of relationship between student and patient is articulated in terms of collaborative knowledge production, involving close reading with the patient as text, through dialogue. Here, a medical 'education' displaces traditional forms of medical 'training' that typically involve individual information reproduction. Students may, paradoxically, improve clinical acumen through consideration of silences, gaps, and contradictions in patients as texts, rather than treating communication as transparent. Such paradoxical effects have been systematically occluded or denied in traditional medical education.
医学生必须为在以患者护理路径为中心的跨专业和多学科临床团队中工作做好准备。虽然围绕以患者为中心的医学教育有很多言辞，但除了在广泛的“专业精神”框架内描述沟通技巧和同理心教育的层面之外，几乎没有尝试对这种实践进行概念化。矛盾的是，虽然旨在加强患者与学生的互动，但这种方法往往重新聚焦于医生的角色示范，而学生与患者之间潜在的深度合作工作关系的机会却被错过了。可能有必要对传统的以医生为主导的医学教育进行彻底改革，这也对以学生为中心的个人主义方法的正统观念提出挑战，从而形成一种真正的以患者为中心的模式，将学习的重点从作为教育者的医生与学生之间的关系转移到患者与学生之间的关系，医生作为资源专家。借鉴当代后结构主义的文本和身份建构理论以及基于工作的学习创新模式，学生与患者之间关系的潜在质量通过协作知识生产来阐述，包括将患者视为文本通过对话进行仔细研读。在这里，医学“教育”取代了传统的医学“培训”形式，传统培训通常涉及个人信息的复制。矛盾的是，学生可能通过考虑患者文本中的沉默、空白和矛盾来提高临床敏锐度，而不是将沟通视为透明的。这种矛盾的效果在传统医学教育中一直被系统地掩盖或否认。
