Chessare J B
Department of Pediatrics, Albany Medical College, New York, USA.
Pediatrics. 1998 Apr;101(4 Pt 2):762-6; discussion 766-7.
The growth of managed care has brought a new focus on physician competency in the appropriate use of resources to help patients. The community of pediatric educators must improve residency curricula and teaching methodologies to ensure that graduates of their programs can effectively and efficiently meet the needs of children and their families. The educational approach in many pediatric residency programs is an implicit apprenticeship model, with which the residents follow the actions of attending physicians with little attention to scrutiny of the clinical evidence for and against diagnostic and treatment strategies. Evidence-based medicine stresses to the trainee the importance of the evaluation of evidence from clinical research and cautions against the use of intuition, unsystematic clinical experience, and untested pathophysiologic reasoning as sufficient for medical decision-making. Managed care also has helped to create a heightened awareness of the need to educate residents to incorporate the preferences of patients and families into diagnostic and treatment decisions. Trainees must know how to balance their duty to maximize the health of populations at the lowest resource use with their duty to each individual patient and family. Changes in the residency curriculum will bring change in educational settings and the structure of rotations. Potential barriers to implementation will include the need for faculty development and financial resources for information technology.
管理式医疗的发展使人们重新关注医生在合理利用资源以帮助患者方面的能力。儿科教育工作者群体必须改进住院医师培训课程和教学方法，以确保其项目的毕业生能够有效且高效地满足儿童及其家庭的需求。许多儿科住院医师培训项目的教育方式是一种隐性学徒模式，住院医师在这种模式下跟随主治医师的行为，很少关注对支持和反对诊断及治疗策略的临床证据进行审查。循证医学向受训者强调评估临床研究证据的重要性，并告诫不要仅靠直觉、非系统的临床经验和未经检验的病理生理推理来进行医疗决策。管理式医疗也有助于提高人们对教育住院医师将患者及其家庭的偏好纳入诊断和治疗决策的必要性的认识。受训者必须知道如何在以最低资源消耗最大化人群健康的职责与对每个患者及其家庭的职责之间取得平衡。住院医师培训课程的变化将给教育环境和轮转结构带来改变。实施过程中的潜在障碍将包括师资发展的需求以及信息技术的资金投入。
