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SP在临床教学中的发展回顾与展望

2016-06-20      查看:1450次      评论:504条      来源:道客巴巴

  标准化病人(Standardized Patient,SP)是指经过特别培训后,能够充分了解临床病人的心理状态和病史并恒定、逼真地模仿其症状,在临床教学及技能考试中扮演病人、教学指导者和评估者等多种角色的人员。SP起源和发展于美国和加拿大,被引入我国也有20多年的历史,它为现代医学教学及考核评估开辟了新的路径。
  一.标准化病人(SP)的发展历史
  1963年,美国南加州大学的Howard Barrows医生在神经病学见习带教活动中首创性地雇佣一名艺术系的模特扮演模拟化病人(Stimulated Patient)来训练医学生的问诊和查体,这便是标准化病人的雏形。此后,这一新兴的教学媒介又被冠与“计划病人”(Programmed Patient)、“病人指导者”(Patient instructor)、“病人演员”(Patient actor)、“专业病人”(Professional Patient)等各式称呼。最终,由加拿大心理测量医生Geoffrey Norman提出的“标准化病人”(standardized Patient)这一称谓在20世纪80年代逐渐被广泛接受和认可,一直沿用至今。
  如今SP作为一种公认而有效的教学方法已被世界各地的医学院校广泛应用于医学教学当中,然而SP在发展初期却历尽坎坷。许多人对这一新兴的教学模式持怀疑态度,批判它过于哗众取宠、费用昂贵,甚至认为雇佣演员来扮演病人亵渎了医学教育的神圣。同行的批判丝毫没有动摇Howard Barrows对SP的热爱,相反,他在应用SP的过程中愈加感受到它的教学和研究价值,并矢志不渝地推广这项教学方法。
  在Howard Barrows的带动和推广下,越来越多的医学教育者开始关注并投入SP教学研究。70年代,亚利桑那大学的儿科医生Paulastillman演变性地将模拟化母亲(Simulated mother)应用到儿科问诊训练中,培训其在专门的表格上记录并评估医学生在问诊中的表现;爱荷华大学的妇产科医生Robert Kretzschmar受Howard的启发,培训了首批妇科学教学助理(gynecology teaching associate,也称为“专业病人”(Professional Patient),她们以自己为模特指导学生掌握正确的盆腔检查手法,同时培养其与患者沟通的能力,在教学中充分融合临床技能和沟通技巧。

  同时,SP的应用领域也不断深化,并逐步扩展到住院医师的培训和评估中。1998年,美国国际医学生教育委员会规定,期望在美国行医的外国学生必须参加多站式SP临床技能考试。2004年,美国执业医师执照考试第二阶段新增了临床技能部分的考核,该环节设置了12个模拟临床工作场景的考站,通过在每一个站点应用SP对学生的临床技能进行现场考核,考生只有英语口语、交流能力、病史采集以及技能操作能力等各方面均合格,才能通过考试。1991年,Paulastillman将SP引入我国。1993年,美国中华医学基金会(CMB)资助华西医科大学、浙江医科大学等多所高校开展了“临床技能教育与评估项目”,培养了我国第一批SP。近年来,国内越来越多的医学院校开始招募、培训和应用自己的SP队伍,在教学实践中取得了良好的效果。


  二.SP被引入中国的背景
  2.1患者和家属自我保护意识不断提高
  传统教学方法以理论授课为主,同时结合门诊或病房的典型病例进行示教。随着民众法律意识的提高,越来越多的患者抵触被医生当作活教材,医学生直接接触病人的机会越来越少,给临床教学工作的开展带来诸多困难。
  2.2高等医学教育规模扩大对传统教学模式的冲击

  随着我国高等医学院校的招生规模不断扩大,可用于教学的病人及疾病种类难以满足医学教学需求。此外,由于临床医生身负医、教、研多重任务,难以实现一对一的带教模式,无法切实保证医学生在早期打下扎实的临床基本功。


  三.SP的主要应用范围
  3.1问诊训练
  在传统教学模式下,教师和学生通常需等待到合适病人的到来才能进行开展问诊实践,但在SP问诊模式下,教师可基于真实的病例资料库设定特定场景,随时随地安排训练。在这个过程中,教师可要求SP扮演特定的病人,设置恐、忧虑、愤怒、敌视等障碍,训练学生应对各种特殊情况的技巧。此外,可在诊疗过程中引导学生如何观察病人、安慰病人以及如何消除病人的顾虑。在反复模拟训练中,使学生逐步掌握问诊中的各种技巧,并在早期培养其以病人为中心的临床思维方式。
  3.2体格检查培训
  将SP应用到体格检查训练中,可有效克服教学病人不足、病人不合作以及被检查者不能向检查者反馈手法有何不足等问题。SP以自己的身体作为教学道具,可以稳定地为学生提供病史和体征,同时增强学生体格检查训练的真实感受。专业的SP不仅能够就学生对病人的态度、沟通方式等给予及时反馈,还可根据自己亲身感知向学生反馈其查体手法、部位等是否到位,与专业教师的指导相互补充。
  3.3考试评估

  除了作为日常教学中的一对一指导者,SP还可运用于大规模的医学考试评估中,比如客观化结构化临床考试(OSCE,Objective Structured Clinical Examination)。传统的单选题、多选题和简答题等考试模式侧重考核考生的机械记忆能力,难以对其临床思维、操作技能以及沟通能力进行客观和全面地评估,灵活的SP考核模式已被越来越多的医学院校所认可,美国、加拿大、日本等国的国家级医学资格认证机构广泛采纳了SP评估方式。


  四.SP的应用亮点与局限性
  4.1应用亮点
  考核形式上的创新:为考核医生在真实就诊环境中的表现,美国南伊利诺伊大学经过规范培训一批SP后,直接把他们匿名安排到医生诊室就诊,结果被考核的临床医生在毫无察觉的状态下完成了考试,最后的分析也证明了SP的评估与医生平时的表现一致;复旦大学在其OSCE考试中不断总结经验,改变了原先SP先进入考站、考生轮转入站的形式,而采用了考生相对固定在一个诊室,由SP轮转到各“医生”所在诊室“就诊”的方式,有效模拟了医生的实际工作场景,更客观地评估了考生的表现。
  教学模式的现代化与智能化:随着医学教育投入的增加,电子标准化病人相继被引入诊断学教学当中。电子标准化病人(SP)通过在外形上仿真,利用教学软件系统来逼真地模拟各种阳性体征,同时配套心电图等诊断素材库,为学生创造一种交互式的教学情景。2007年,中山大学引进了电子标准化病人5000型,并将其系统地应用于诊断学实践教学和相关基础课程中。调查显示,90%以上的学生认可这一新型的教学模式,并认为它可有效提高自身的综合诊治技能和培养初步的临床思维能力。
  对SP招募途径的深化:早在20世纪70年代,Paulastillman就提出了应用慢性病患者担任SP的设想,筛选和培训了患有心脏杂音,支气管炎、主动脉狭窄等疾病的慢性病人作为体格检查SP,并收到了良好效果。该模式的优点在于慢性病患者不经任何培训便呈现出阳性体征,既减少了培训成本,又可为学生提供稳定、真实的临床体征,从而有效地培养其辨别异常体征的能力。另外,台湾的SP招募方式也值得借鉴。台湾的许多医院均设有标准化病人中心,他们选择性地从教会成员和义工队伍中发展SP,此类成员比较具有奉献精神和责任心,便于维护团队的稳定性。
  对临床体征模拟范围的拓宽:一般认为SP可模仿的临床体征范围较小,然而很多研究指出SP可模仿的范围远超出原本的设想。Howard Barrows基于30多年的教学研究,罗列出了一份包含60多种可以模仿的阳性体征清单,如气胸、腹部压痛、过敏性休克等。他曾严格培训了若干名SP,并在相关的教学研讨会上进行展示,这些训练有素的SP对高难度的阳性体征的模拟令在场的各医学院校观摩者叹为观止。反馈体系上的完善:虽然SP不能代替临床教师的角色,但充分利用SP的反馈信息尤为重要。例如,在OSCE考站中可预设一定的时间,以便SP给予学生及时的口头反馈,促进考生更好地体验病人感受和换位思考,教师也可从侧面了解存在的问题。
  SP的多样化:部分高校为更好地提高八年制和留学生的教学质量,专门招募了英文系毕业或英文水平较好的社会人士担任SP,丰富了临床实践教学内容。
  4.2 SP的局限性

  培训专业的SP需要投入大量的资金和时间,并且维护成本高,医学院校往往缺乏足够的资源培训和维持一支稳定的SP团队。SP与真实病人之间存在较大区别,虽然能够模仿一些常见体征,但能够模仿的疾病种类和症状有限,不能替代病房实践。SP案例多为典型性病症和病例,而临床所遇到的病例并不都是典型的,学生从中掌握的实际经验有限。SP所提供的信息大部分为预先设定的,仍存在较大的自由发挥空间,培训者难以把握好SP的“标准化”和“可重复性”。由于SP一般为非医学专业人士,加上国内缺乏专业的SP培训机构,SP作为评估者和指导者所发挥的作用比较有限。


  五.SP在我国的发展情况及存在的问题
  5.1缺乏国家层面的政策引导
  在美国,医师执照考试对医学教育和课程改革的导向性影响显而易见,而将SP应用于该项考试直接奠定了SP在临床技能评估中的地位和作用。全美各高校在该考核模式的引导下,潜移默化地将SP模式贯穿于整个医学教育领域。然而,我国由于缺乏国家层面的政策引导,SP的应用范围更多集中于医学生教育,在住院医师培训和考核等方面的应用仍相对有限,且大多数仅用于OSCE考试。
  5.2缺乏专业的SP培训团队
  在国外,经过近50年的发展和完善,已逐渐形成了职业化的SP以及以培训SP为职业的SP培训师,这无疑为医学院校提供了稳定而优质的SP队伍。目前,我国的SP招募主要延续社会志愿者和学生SP两种模式,志愿者大多为社会退休人员、院内就诊患者和医学生等,人员流动性强,SP队伍稳定性差。此外,国内缺乏专业的SP培训团队,许多SP项目大多局限于模仿和照搬欧美模式,真正适合我国国情的SP发展模式仍有待摸索。
  5.3 SP发挥的作用相对有限

  在我国SP主要发挥着“病人”的角色,扮演体格检查的真人模特或充当被问诊的对象,但其作为评价者和指导者的角色发挥十分有限。换而言之,SP更多是充当被动的“教学工具”,还未能承担起教师的评估者和指导者角色,做到准确记录并有效反馈信息。


  六.未来的研究及应用方向探讨
  随着SP研究和应用的不断深入,对SP的要求不应停留在“病人扮演者”的初级阶段,应进行更深层次的培训,使其担当起评价者和指导者的角色,但由于我国缺乏美国和加拿大等国家积极推行SP的教学氛围,如何推动SP的专业化与职业化仍任重道远。
  在实际教学中,可将SP与模型、高端模拟人等充分结合,使问诊、体格检查和临床技能操作等内容的训练融为一体,从而更有效地培养学生的临床整体思维。在问诊、体格检查训练中SP的优势不言而喻,实际上它在技能操作培训方面也有着模型无法比拟的优势。对于如骨折固定之类的无创技能操作,应用SP远远优于模型;对于有创或侵入性的操作,应避免在SP身上进行,可直接用仿真模型代替,或为SP配套如模拟创伤口等可穿戴式的模具或设备,从而既保护了SP又为学生还原了真实的诊疗情境。
  此外,SP教学模式不只局限于医学教育领域,它同样对某些需同时考核应试者的专业技能和沟通能力的领域有着重要的借鉴意义。据相关文献报道,类似的模式也被应用于针对教师、职员等开展的培训与考核,标准化病人(SP)概念被进一步拓展至标准化教师、标准化学生和标准化客户等。例如,在教师能力考核中应用标准化学生,通过培训其扮演各类常见的学习者,可更有效地评定教师在真实情境下的教学能力;在法学教育中,纯理论考试容易误导考生追求法条记忆能力,通过在考试中设置标准化客户、标准化法官等,可更好引导考生培养独立分析和办理案件的能力。

  总而言之,SP教学模式已在其发展的几十年里经受了时间的考验,并被世界各地医学教育者不断完善和丰富,在日常医学教学和考试评估中发挥着越来越重要的作用。然而,我国对SP的应用和研究有待完善,国际的SP应用经验也未必适用于我国,它的推广仍需教育管理部门和医学院校的共同努力,从而探索出适合国内医学教育环境的SP模式。


参考文献:
[1] Pwallace.Following the threads of an innovation:the history of standardized patients in medical education[J].Cana-dian Metallurgical Quarterly,1997,13(2):5-28.
[2] Howard S.Barrows.An Overview of the uses of Standardized Patients for Teaching and Evaluating Clinical Skills[J]. Academic Medicine.1993,68(6):443-449.
[3]俞方.美国医学课程改革历程探索[M].北京:人民卫生出版社,2010:107-112.
[4] Nu viet Vu,Howards.Barrows.Use of Standardized Patients in Clinical Assements Recent Developments and Measurement Findings[J].Educational Researcher.1994,23(3):23-30.
[5]周金美,林玉坤,钟叶彬,等.电子标准化病人在诊断学教学中的应用[J].中国卫生产业,2012,(2):91-91,93.
[6]曾勇,邹和建,鲁映青,等.OSCE的持续改进:复旦大学上海医学院的经验[J].复旦教育论坛,2008,6(3):94-96.
[7]钟玉杰,王敏,李勤.从10年文献回顾分析我国标准化病人教学的发展[J].中华护理杂志,2009,44(3):259-261.

[8] Sweeney,J.,&Manatt,R.P.(1996). Teacher evaluation.In R.A.Berk(Ed.),Performance assessment:Methods and applications.Baltimore:John Hopkins -University Press.

                                                                作者:黄春锋,杨素清,林慧芳,冯劭婷

                                                           (中山大学附属第一医院,广东广州 510080)

(本文来自:西北医学教育(http://xbyx.cbpt.cnki.net)2014年8月第22卷第4期)

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