怎樣成為好醫(yī)生

1、怎樣成為好醫(yī)生What makes a good doctor,怎樣成為優(yōu)秀的全科醫(yī)生”,What makes a good doctor什么是好醫(yī)生,“The doctor should have a kind disposition, great patience, meticulous freedom from prejudice, an understanding of human nature resulting from

2、 an abundant knowledge of the world, adroitness in conversation and a special love of his calling” G Greisinger 1840Big 3 attributes- caring, responsibility, knowledge,“醫(yī)生應(yīng)該有良好的氣質(zhì)，極大的耐心，謹(jǐn)慎地不帶成見，通

3、過豐富的閱歷理解人的屬性，機(jī)智靈敏地與別人交談，對病人充滿愛心” G Greisinger 1840 3個重點(diǎn)： － 關(guān)懷 － 責(zé)任 － 知識,– 12條指導(dǎo)原則,好醫(yī)生應(yīng)該有自己的指導(dǎo)原則。我認(rèn)為，作為這個崇高和偉大的職業(yè)群體的一員，我們應(yīng)該努力地讓病人、同行和社會把我們看成一流的專業(yè)人員。,Develop rapport & good com

4、munication skills建立尊重和良好溝通機(jī)能,Big 2: listening best nameOthers: friendly greeting respect and courtesy well briefed non-judgemental,2個要點(diǎn): 傾聽 稱呼名字 其他:

5、 友好地招呼病人 尊重和有禮貌 言簡意賅 不帶偏見,3 golden communication rules溝通的三個黃金法則,Listen傾聽Call patient by preferred name用病人的名字稱呼病人Appropriate touch采用適當(dāng)?shù)姆绞接|摸病人,History-some guiding rules病史： 一些基

6、本規(guī)則,The provisional diagnosis should come from the historyBelieve the patientAlways believe a worried parentSee patient alone if possibleAsk the patient what they consider is their real problemThree incorrect strike

7、s and it’s out!,初步的臨時診斷應(yīng)該從病史中發(fā)現(xiàn)要相信病人要永遠(yuǎn)相信患兒父母如果可能，最好單獨(dú)看病人詢問病人，問他認(rèn)為真正的問題是什么,2. Ask the right questions 詢問正確的問題,Why have you come to see me today?Do you have any particular concerns about your health?Tell me about

8、 things at home?Tell me about things at work?What do you think deep down is the cause of your problem?Is there anything that I haven’t asked you and that it would be best if you told me?Is there anything in your life

9、 that you would like to change?,你今天是什么原因來找我？你具體擔(dān)心自己哪方面的健康問題？告訴我你在家里的情況？告訴我你在工作單位的情況？你認(rèn)為你的病的深層次原因是什么？有沒有我沒有問到，但你想告訴我的事情？你是不是想過改變一下自己的生活？,3. Be astute and observant 機(jī)敏并善于觀察,The art of physiognomy (Addison)-- the

10、art of reading both physical and emotional problems from the face and body language“Watson you see everything but observe nothing” Sherlock Holmes,相面術(shù) － 通過表情和身體語言閱讀軀體和心理問題的藝術(shù)“華生醫(yī)生，你看到了全部，但什么也沒觀察到” － 福爾摩斯,H

11、istory: general symptoms(often overlooked-”red flags”)常見癥狀（通常忽略，紅色警戒事件）,Tiredness/malaise fatigue勞累，不適，疲勞Fever/sweats發(fā)熱，出汗Weight change體重變化Unusual lumps or bumps 異常腫瘤或腫塊Pain or discomfort anywhere疼痛，或周身不適Unus

12、ual bleeding異常出血Ask: “is there anything else you should tell me about?”詢問： 還有沒有你應(yīng)該告訴我的其他事情？,The skill of accurate diagnosis at point of first contact初次接診的準(zhǔn)確診斷技術(shù),Questions to ask oneself 問自己幾個問題1 What is the probabi

13、lity diagnosis?可能的診斷是什么？2. What serious disease must not be missed不能忽視的嚴(yán)重疾病是什么？3. What conditions are often missed-pitfalls?通常會存在什么陷阱？ 4. Could the patient have a masquerade?病人是不是戴著面具？5. Is the patient trying to

14、tell me something?這個病人是不是想要告訴我什么？,4. Develop optimal ethical & professional standards 遵循道德和職業(yè)規(guī)范,Hippocratic oathThe Declaration of Geneva希波克拉底誓言日內(nèi)瓦宣言----------------------,Cardinal 醫(yī)生的美德 最首要的- prud

15、ence, justice，courage,temperance謹(jǐn)慎，判斷，勇氣，克制Key- generosity 大度寬容 - compassion 同情憐憫 - tolerance 寬容寬恕 - gentleness 溫情和善 - politeness 禮貌客氣 - humour 詼諧幽默,5. Have a fail-safe diag

16、nostic strategy第五條：采用“保險(xiǎn)”的診斷策略,What is the probable diagnosis?What must not be missed?What are the pitfalls? Have I learned from past mistakes?Is the patient trying to tell me something? Hidden agenda/ ticket of entr

17、y What tests should I order?,可能的初步診斷是什么？一定不能忽略哪些嚴(yán)重疾病？會不會有陷阱？我從以往的錯誤中學(xué)到什么？ 我應(yīng)該讓病人做什么檢查？,Classic minefield problems conditions prone to error典型的容易發(fā)生診治錯誤的問題,Acute abdominal pain急性腹痛Acute chest pain急性胸

18、痛Breast lumps乳房腫塊Headache頭痛Cough咳嗽Children’s disorders especially infections兒童問題，特別是感染Endocrine disorders內(nèi)分泌問題,Signs-red flags跡象 － 紅色預(yù)警情況,PallorCyanosisAltered conscious state Cold extremitiesTachypnoeaTa

19、chycardiaFever- temperature > 38º CPoor capillary refill > 2 secs,面色蒼白紫紺神志狀態(tài)變化 肢體末端溫度低呼吸急促心跳過速發(fā)燒－體溫>38ºC微血管回復(fù)充盈差> 2 secs,The 7 first line masquerades七種最常見的戴化裝面具的疾病,DepressionDiabetesD

20、rugs iatrogenic self abuse and OTCAnaemiaThyroid & other endocrineSpinal dysfunctionUrinary infection,抑郁癥糖尿病藥物問題 －因醫(yī)生引起的 －自己藥物濫用 或非處方藥貧血甲狀腺病或其他內(nèi)分泌疾病脊柱功能損傷尿路感染,Classic pitfa

21、lls (red faces)典型的陷阱,Abscess (hidden)AllergiesChronic fatigue syndromeCoeliac disease Domestic abuse inc.childrenDrugsHerpes zosterFaecal impactionForeign bodiesGiardiasisHaemochromatosis,膿腫暗瘡各種過敏慢性疲勞綜合癥腹腔疾

22、病家庭暴力，包括虐待兒童藥物濫用帶狀皰疹大便干燥異物賈第鞭毛蟲病血色素沉著癥,Classic pitfalls (red faces) cont典型的陷阱（續(xù)）,Malnutrition (unsuspected)Menopause syndromeMigraine (atypical variants)Paget’s diseasePregnancySarcoidosisSeizure disorders

23、Tourette’s syndrome,營養(yǎng)不良（未曾發(fā)現(xiàn)）絕經(jīng)期綜合癥偏頭疼（非典型性）佩吉特病（濕疹樣皮損）懷孕皮膚結(jié)節(jié)病癲癇發(fā)作多發(fā)性抽動癥,Is the patient trying to tell me something?病人是不是想告訴我什么？,Hidden agenda‘Ticket of entry’Masked depressionUnderlying anxiety/fearsConflic

24、ts-at homeConflicts-at workBullyingSexual issues inc STIs?Munchausen’s,藏在心里的目的要張‘門票’隱藏的抑郁潛在的焦慮或恐懼在工作場所和別人有矛盾被人欺負(fù)與性有關(guān)的問題，包括性傳播疾病,6.Develop your own guidelines 制作你自己的指南,For diagnosis and management of common sy

25、mptoms e.g. headache, back pain, acute chest pain, rash, acute abdominal pain, breast lumps sick febrile child common conditions eg angina, diabetes, hypertension,cardiac failure,asthma, epilepsy,診治常見癥狀，如頭疼，背痛

26、，急性胸痛，皮疹，急性腹痛，乳房腫塊，小兒發(fā)熱診治常見疾病，如心絞痛，糖尿病，高血壓，心衰，哮喘，癲癇,,教科書上的指南是有用的，不過好醫(yī)生會制定出適合自己的指導(dǎo)原則。醫(yī)生可以列出診斷和治療常見癥狀的“自我指南”，比如頭疼、背疼、出疹、胸痛的診治方法，并且把這些癥狀與相關(guān)的疾病聯(lián)系起來，如糖尿病、心絞痛、哮喘等。善于歸納出自己的指南，實(shí)際上是醫(yī)生能更好地理解這些常見癥狀和疾病。特別是，醫(yī)生要能夠謹(jǐn)慎地對醫(yī)療保險(xiǎn)機(jī)構(gòu)確定的那些疾病進(jìn)

27、行診治，因?yàn)檫@些疾病的處理不當(dāng)，可能導(dǎo)致醫(yī)療賠償或訴訟。有六種癥狀：胸部腫塊、急性胸痛、急性腹痛、小兒發(fā)燒、嚴(yán)重頭疼、急性呼吸困難。,7 Develop supportive networks 建立支持網(wǎng)絡(luò),Know your consultants/hospitals附近的專家和醫(yī)院 Colleagues Phone其他全科醫(yī)生及電話Social workers phone

28、社會工作者及電話Religious/counsellors phone宗教人士及電話Allied health team phone輔助醫(yī)療團(tuán)隊(duì)及電話,CAT team危重病人評估小組Psychiatric services精神病學(xué)服務(wù)Internet互聯(lián)網(wǎng),8.Know essential therapeutics 掌握基本的治療技術(shù),Know your key drugs by heart and

29、the prescribing issuesKeep up to date Avoid using drugs if there is an alternative- consider complementary strategiesBe good at treating ‘nitty gritty’ problems eg dandruff, halitosis, cramps, warts, tinea, eczema,

30、 stress, mouth ulcers, anxiety, lumbago, pruritus ani and vulvaePromote patient education handouts extensively,牢記主要的藥品，及其處方注意事項(xiàng)掌握最新的用藥情況 如果可以考慮用其他的替代方法，則不要用藥善于治療‘小毛病’，如掉頭皮屑，口臭，抽筋，疣子，皮癬，濕疹，緊張，口腔潰瘍，焦慮，腰肌勞損，肛門搔癢，外陰搔癢

31、給病人健康促進(jìn)資料,掌握基本的治療方法,好醫(yī)生應(yīng)該非常熟悉經(jīng)常使用的藥品，并為病人準(zhǔn)備好這些藥品的說明書。醫(yī)生還要掌握不斷出現(xiàn)的新藥，在可能的情況下替換原來的舊藥。這一點(diǎn)對于治療精神疾病的藥物來說特別有用，如抗抑郁藥和抗精神病藥。對于每天可能遇到的那些“實(shí)際問題”，醫(yī)生也要有好的治療方案，如頭皮屑、口臭、口腔潰瘍、腳癬、肉疣、抽筋、濕疹、瘙癢，等等。如果采用改變生活方式、自然療法、補(bǔ)充維生素就能夠解決問題的，就盡量避免使用復(fù)雜的藥物

32、治療。給病人準(zhǔn)備好健康教育資料。,9. Develop basic procedural skills 掌握基本的操作技術(shù),Advantages continuing skills improvement more interesting and satisfying work cost effective for your patients,好處持續(xù)地改進(jìn)操作技術(shù)，可以讓醫(yī)生對工作更有興趣，對工作更滿意

33、有助于提高診治病人的成本效益,,病人非常敬佩醫(yī)生的地方，是他們能駕輕就熟地使用那些“家伙”，如聽診器、檢耳器、檢眼鏡、直腸鏡等診斷輔助器械。病人還非常欽佩醫(yī)生能靈巧處理常見疾病，如耳道清洗、創(chuàng)傷縫合、切除原發(fā)腫塊、拔除異物、頸部和腰部理療、肌肉骨骼系統(tǒng)系統(tǒng)疾病的注射治療等。,10. Be prepared for emergencies 準(zhǔn)備好應(yīng)對緊急情況,Managing emergency conditions is

34、a huge but interesting and rewarding responsibilityBe prepared-plan, equip, practice,對緊急情況的診治需要大量的工作，不過從中可以學(xué)到很多知識和經(jīng)驗(yàn)，而且也體現(xiàn)的醫(yī)生的責(zé)任所在要準(zhǔn)備好 － 計(jì)劃，設(shè)備，服務(wù),,準(zhǔn)備好基本的急救措施很多病人病得很嚴(yán)重，他們有可能就倒在醫(yī)生面前。好醫(yī)生應(yīng)該準(zhǔn)備好基本的急救措施，能操作基本的急救設(shè)備，對病人的突發(fā)情況給與

35、快速的反應(yīng)。醫(yī)生應(yīng)該具備如下能力：掌握心肺復(fù)蘇技術(shù)，搶救心臟驟停的病人針對過敏性反應(yīng)的急救措施針對呼吸窘迫的急救技術(shù)，如哮喘、急性肺水腫、哮吼急性心肌炎或心肌梗死的急救腎和膽絞痛的處理驚厥的處理,第十一條：掌握特定服務(wù)的專門技能,針對需要特定服務(wù)的人群，醫(yī)生要制定和遵守明確和符合倫理的原則。這些特定人群包括：年老體弱者，比如家庭診療技術(shù)社會弱勢群體先天發(fā)育和智力障礙群體絕癥患者，比如提供姑息關(guān)懷各種傷害的受害者土

36、著人（少數(shù)民族）難民,第十二條：了解自己，了解自己的局限性,醫(yī)生要知道自己知識和技能的局限，要準(zhǔn)備好請教別人，尋求別人的幫助。記住這個“棒球規(guī)則”：三振出局（事不過三，即不能總犯同樣錯誤）。醫(yī)生要能從工作中找到樂趣，喜歡自己的工作。醫(yī)生擁有與病人交往的神圣特權(quán)，因此也應(yīng)該從中得到最大的收益。,“好醫(yī)生就是善待病人” 人民日報(bào)短文,每個醫(yī)生在心里都有自己的“好醫(yī)生”標(biāo)準(zhǔn)，你的標(biāo)準(zhǔn)是什么呢

37、？,Practice tips全科醫(yī)學(xué)服務(wù)要訣,,Tips in children給兒童提供服務(wù)的要訣,Removing plaster-soak in waterLacerations ion scalpClearing the snotty noseGetting the mouth open-pinch testInstilling nose drops-over nares-cover mouthCutting p

38、laster-use tongue depressorAbdominal palpationFirm round foreign body in nose,創(chuàng)可貼，石膏，膠布：在水里揭頭皮內(nèi)創(chuàng)傷處理清理鼻涕讓兒童張口（捏鼻）滴鼻液：在鼻孔上，捂嘴切石膏：使用壓舌板腹部觸診方法在鼻子上固定,Nitty gritty tips小毛病的服務(wù)要訣,Seasickness: plug one ear; ginger; look

39、 to the horizonNightmares: anti-epileptics phenytoin; epilumHiccups: breakfast question; 20 ml spirit in teaspoon sugar; breath hold + iceErectile dysfunction: Viagra etc; consider ischaemic heart diseasePremature e

40、jaculation: SSRI eg Prozac dailyPremenstrual tension: SSRI 10 days before M,暈車暈船: 塞住一只耳朵，生姜，眼看前方做惡夢: 抗癲癇藥，苯妥英，丙戊酸鈉呃逆，打嗝: 早餐問題; 20 ml 酒加一小勺糖; 屏住呼吸＋冰勃起困難: 偉哥; 考慮是否患冠心病早瀉: 選擇性5-羥色胺再吸收抑制劑SSRI，如百憂解，每天1次經(jīng)前期緊張: 月經(jīng)來前10天吃SS

41、RI,Pain in the knee trap奇怪的膝蓋疼,Hip joint-L3 innervationKnee pain-think hipBeware children with slipped upper femoral epiphysis,髖關(guān)節(jié)－L3神經(jīng)支配膝蓋疼要想到臀部問題兒童要注意是否上股骨端脫臼,Tennis elbow網(wǎng)球肘 – 肌腱炎,Muscle strengthening exercises

42、best for tendonitis肌肉強(qiáng)度練習(xí)，對肌腱炎有好處For medial epicondylitis (tennis elbow)-extensors of wrist醫(yī)學(xué)上的肱骨上髁炎（網(wǎng)球肘）- 腕伸展肌,Trochanteric bursalgia大轉(zhuǎn)子滑囊炎,Common in females >45-50 yearsPain on outside hip-? referred as far as

43、footPain lying on hip at nightLimpRx Physio & exercises Massage Trial NSAIDs Injection local anaesthetic and corticosteroid,45-50歲以上婦女常見 髖外側(cè)疼 － 可能波及到腳夜間髖部疼痛走路跛行處方 理療和鍛煉 按摩 非

44、類固醇抗炎藥 局部麻醉劑注射 以及皮質(zhì)類固醇,Treatment of Plantar fasciitis足底筋膜炎的治療,Orthotic aids eg Rose insoleHydrotherapy-hot and cold water 30 seconds each –alternate 15 timesTherapeutic foot massageExercisesNSAIDS-3 weeks

45、Injection under tibial nerve block,矯正器，如羅斯鞋墊水療 － 冷熱水每30秒交替一次，共做30次治療性足按摩鍛煉非類固醇抗炎藥－ 3周注射 － 脛骨神經(jīng)封閉,Torsion of testicle “a time bomb”睪丸扭轉(zhuǎn) － 定時炸彈,Common cause of litigationAge range 5-15 (early teens)85% salvageable

46、within 6 hoursMost lost with delays on investigationRefer immediately to surgeon/centreTeenage boys maybe diagnosed as appendicitis,常見的訴訟原因年齡范圍5-15歲(青少年早期)85%的病例可以在6個小時內(nèi)得以挽救大多數(shù)不可挽回的病例耽誤在檢查上立刻轉(zhuǎn)診到外科或醫(yī)學(xué)中心年輕男孩

47、可能被誤診為闌尾炎,Removal of foreign bodies清除異物,Splinter under nail扎在指甲里的碎片F(xiàn)ish hook釣魚鉤Splinter in skin扎在皮膚里的碎片,Pulled elbow in children兒童的牽引肘,Reduce by supination用反掌姿勢復(fù)位,Simple trauma traps and tips小外傷的陷阱和要訣,Missing a

48、foreign body: glass, gravel, splinters, needleMissing a ruptured tendonExposed joint capsule in wrist: watch fist punchBites-human, cats, dogsHigh pressure guns-oil and paintStab wounds: nerves, tendonsCut finger o

49、r toeTourniquet left on fingerBeware jumping from height onto feet-fractures, concussBeware painful elbow in childBeware scaphoid fracture after fall on outstretched hand,沒找到扎在身體里的異物：玻璃，沙礫，碎片，針沒找到斷裂的肌腱腕關(guān)節(jié)囊暴露：拳擊咬傷

50、－ 人，貓，狗高壓槍 － 油或油漆暴露傷: 神經(jīng)，肌腱切手指或腳趾止血帶留在手指上當(dāng)心從高處跳下 － 骨折，腦震蕩當(dāng)心兒童的肘痛當(dāng)心舟骨骨折 － 摔倒后手觸地,Neck dysfunction-muscle energy therapy頸部功能失常 － 肌能治療,A simple safe treatment簡單安全的治療,Back pain treatment背痛的治療,Mobilisation & man

51、ipulation搬運(yùn)和操作Exercises練習(xí),Management-lifestyle advice-NEAT疾病管理－對生活方式的建議,N= Nutrition: optimal diet, low fat合理營養(yǎng)：優(yōu)化飲食結(jié)構(gòu)，低脂飲食，維生素，礦物質(zhì)，多喝水E= Exercise: physical activity加強(qiáng)鍛煉：讓身體活動起來A= Avoid toxins- ‘cats’： caffeine,

52、alcohol, tobacco, sugar, salt, social drugs遠(yuǎn)離毒物： 咖啡因，酒精，煙草，糖，毒品T= Tranquillity- rest & recreation, stress management, yoga, meditation, good sleep心態(tài)平靜： 休息娛樂、減少壓力，瑜伽，靜坐,Hypertension高血壓,Lifestyle modification-alcoh

53、ol, smoking etcManage associated conditions eg diabetesMedication-need 4-6 weeks trial 1. start with ACE/ARB or CCB or thiazide 2. ACE/ARB + CCB (best evidence) or thiazide 3. ACE/ARB + CCB + thiazide,改變生活方式 － 吸煙，飲

54、酒等管理好相關(guān)的疾病，如糖尿病用藥 － 需要4-6周的試驗(yàn) 先用血管緊張素轉(zhuǎn)換酶抑制劑ACE/血管緊張素受體拮抗劑ARB或鈣通道阻滯劑CCB或噻嗪類利尿劑ACE/ARB + CCB(證據(jù)顯示效果最好)或噻嗪類利尿劑ACE/ARB + CCB + 噻嗪類利尿劑,Diabetes mellitus-step up management糖尿病 － 建立管理計(jì)劃,Lifestyle management-diet, exercise

55、Oral monotherapy-metformin (choice 1) or sulfonylureaCombination oral therapy metformin + sulfonylurea (? Gliptin)Add a glitazone or other agentAdd insulin-isophane or long acting,管理生活方式 － 飲食，鍛煉單藥口服治療 － 甲福明

56、二甲雙胍 (首選)或者磺脲聯(lián)合口服治療 －甲福明二甲雙胍 ＋ 磺脲（或格列?。┘痈窳型右葝u素 － 精蛋白胰島素或長效胰島素,Urinary tract infection (uncomplicated)尿路感染（無并發(fā)癥）,Urine dipstickMicro-culture (clean catch)High fluid intake-? wait 3 day and see ruleAntibiotics-tri

57、methoprim or cephalexinAlkaliniser especially severe dysuriaRepeat MCU 1 to 2 weeks after AB courseConsider further investigation,尿常規(guī)顯微培養(yǎng)給大量液體？等3天看結(jié)果抗生素 － 甲氧芐氨嘧啶或頭孢氨芐堿化劑，特別是嚴(yán)重的排尿困難1－2周后重復(fù)膀胱造影檢查，after AB course考慮

58、進(jìn)一步檢查,Sore (streptococcal) throat咽痛（鏈球菌感染）,4 key features and indication for penicillinFever >38 CTender cervical lymphadenopathyTonsillar exudateNo coughOthers: those 3-25 years with presumptive GABHS from spec

59、ial communities with a high incidence of rheumatic fever,4個病癥，需要用青霉素發(fā)燒 >38 C頸部淋巴結(jié)腫大扁桃體滲出液不咳嗽另外：特定的風(fēng)濕熱高發(fā)社區(qū)3－25歲人群A組β-溶血性鏈球菌,Otitis media- children兒童中耳炎,Possible clinical indicators for antibioticsSick child with

60、 feverVomitingRed-yellow bulging ear drumLoss of drum landmarksPersist fever and pain after 3 days of a conservative approach,可以使用抗生素的臨床指標(biāo)兒童虛弱，發(fā)燒嘔吐耳鼓蓬出耳鼓邊緣消失保守治療3天后持續(xù)發(fā)燒和疼痛,Otitis media in children -2兒童中耳炎2,Rest

61、 in warm room with adequate humidityParacetamol suspension in high dosageDecongestants only if nasal congestionAntibiotics as indicated eg amoxycillin 40 mg/kg/d in 3 divided doses for 7 daysFollow up in

62、cluding hearing in 10 days,休息房間保持溫暖和適宜的濕度大劑量撲熱息痛輸液如果充血，給抗充血劑抗生素，如 阿莫西林40mg/kg/d， 分每天3次，用7天10天內(nèi)隨訪，包括耳檢查,Think fast with infarction對血栓的快速考慮,Intervention time rulesAcute coronary states- 60-90 minutes to

63、coronary unitStroke- cerebral infarct- 3-4 hours to stroke unitFemoral artery 4 hours 4 hours=limb salvage>6 hours=amputationTorsion of testis 4-6 hours,干預(yù)時間的規(guī)則急性冠心?。?60-90分鐘內(nèi)送冠心病科 腦卒中，腦血管栓塞：3-4小時內(nèi)送腦卒中科股動脈4小時