INTRODUCTION TO INTERNAL MEDICINE

Jiyao Wang, MD. MSC.

Professor & Chair

Dept. of Internal Medicine

Shanghai Medical College,

Fu Dan University

Internal Medicine

Surgery

Pediatricsgynecology

Pathology

MicrobiologyGeneticsBiochemistry

Pharmacology Pathologic-physiology

Diagnostics

Immunology

How to Teach Internal Medicine

• 2005.2-7: Lecture (Bilingual teaching)

• 2005.9-2006.1 Bedside teaching:

rotation for 6 weeks, including

Respiratory system, Cardiovascular system,

Gastrointestinal system, Kidney and urinary system, Endocrinology, Hematology, etc.

Bedside Teaching• Cardiovascular system ： Heart failure( 心衰 ) ； CHD

( 冠心病 )/ Hypertension( 高血压 ) ； Cardiomyopathy( 心肌病 )/ pericarditis( 心包炎 ) ；

Arrhythmia( 心律失常 ) ； • Respiratory system ： ARDS( 呼衰 )/COPD ； Pneumo

nia( 肺炎 ) ； TB( 肺结核 )/ Hydrothorax( 胸腔积液 ) ； Lung Cancer( 肺癌 ) ；

• Gastrointestinal system ： Cirrhosis( 肝硬化 ) ； Peptic ulcer( 消化性溃疡 )/ upper GI bleeding( 上消化道出血 ) ； IBD( 炎症性肠病 )/ diarrhea( 腹泻原因待查 ) ； Acute pancreatitis( 急性胰腺炎 )/ abdominal pain( 腹痛待查 ) ；

Bedside Teaching

• Kidney and urinary system ： Glomerulonephritis (primary and secondary)( 原发性肾小球疾病；继发性肾小球疾病 ) ； Chronic Renal Failure( 尿毒症 ) ； urinary tract infection( 尿路感染 )

• Hematology ： Leukemia( 白血病 ) ； Anemia( 贫血 ) ； Lymphoma( 淋巴瘤 ) ； Disorders of hemostasis ( 出血性疾病 )

• Endocrinology ： Diabetes Mellitus( 糖尿病 ) ； Hyperthyroidism( 甲亢 ) ； hypothyroidism( 甲减 ) 。

 

Time Mon. Tues.

Wes. Thurs.

Fri.

Mor-ning

7:30-9:45

Take history and physical examination, and follow morning round

10:0011:30

Bedside teaching

Afternoon

1:30-4:30

Lecture Case Study Lecture Lecture

确保床旁教学质量

组织上落实是开组织上落实是开展床旁教学展床旁教学的的必必要条件要条件 经过反复讨论和修经过反复讨论和修正，制订计划，保证正，制订计划，保证了组织上落实了组织上落实。。 66 个个科各派出一位专职老科各派出一位专职老师参加床旁带教工作师参加床旁带教工作。。

内分泌科和心内科师生在进行病例讨论

Reference Books• 希氏内科学精要 Cecil Essentials of Medicine• Harrison’s Principles of Internal Medicine• 现代内科学英语精要 人民卫生出版社 2002• 陈灏珠主编 . 实用内科学 . 人民卫生出版社 2

005• 王吉耀主编 内科学试题与题解 上海科学技术

文献出版社， 2002• 王吉耀主编 内科临床病例分析－双语学习 ,

人民卫生出版社 2005

How to learn

1. To combine internal medicine with basic scientific knowledge

2. To combine theory with practice

Start

Told what we Need to know

Learn it

Given problem to illustrate how to use it

Subject based learning

Lectures

• Approach to patients

• Pathogenesis

• Pathologic-physiology & Clinical features

• Diagnosis

• Treatment

Basic theory Basic knowledge Essential skill

Start

Problem posed

Identify what We need to know

Learn it

Apply it

Problem-based learning

To Learn How To Learn

An educational method that allow you to learn about medicine as you attempt to deal with real-life medicine situations.

To develop effective reasoning skills through

• Information gathering

• Problem synthesis

• Hypothesis generation

• Data analysis

• Decision making

Learning of skills

• Inquiry skills

• Thinking skills

• Problem solving skills

Clinical decision making

• 4 steps for dealing with clinical problems:

1. Making diagnosis

2. Identify the severity of the disease

3. According to the severity of disease, to make therapeutic protocol

4. Follow up the results of the treatment

Clinical thinking ( 临床思维 )

• Diagnostic ( 诊断思维 )

• Therapeutic ( 治疗思维 )

Diagnostic thinking skills• History Taking

• Physical examination

• Hypothesis of diagnosis

• developing a differential diagnosis

• Searching the evidence

• Select the related lab. tests and other techniques

A 45 year-old man presented on Jan. 28, 2004 to the emergency department with melena for three times and vomiting of blood.

Key information Problem Hypothesis Rx

45 yr. M GI ulcer

GI bleeding cancer

varices

drug-induced

The Principles of Diagnostic Thinking

• 一元论

• 多考虑常见病

• 先考虑器质性疾病，后考虑功能性诊断

• 用排除法作鉴别诊断

The principles for selecting Diagnostic tests

• 先了解所选试验的有效性、安全性和价格• 排除诊断时，选敏感度高的试验• 肯定诊断时，选特异度高的试验• 首选无创伤性的检查• 当检查结果与临床不符时，应作详细分析而不能

片面依赖实验检查结果

The Principles of Therapeutic Thinking

• 分清轻重缓急

• 一般而言，先明确诊断，再作出治疗计划

• 危重疾病应抢救在先，明确病因再后

• 用药力求简单

• 重视药物的毒副作用和交互作用

The Principles of Therapeutic Thinking

• 可治性疾病应尽早治疗

• 有时可用试验性治疗来进一步验证临

床诊断

• 制订治疗计划时应遵照循证医学的原

则

Evidence-based medicine, EBM

• Best research evidence– basic sciences of medicine– patient-centered clinical research

• Clinical expertise– ability to use our clinical skills and past experience to rapidly i

dentify each patient’s unique health state and diagnosis, their individual risks and benefits of potential interventions

• Patient values– the unique preferences, concerns and expectations each patient

brings to a clinical encounter and which must be integrated into clinical decisions if they are to serve the patient

When these three elements are integrated, clinicians and patients form a diagnostic and therapeutic alliance which optimizes clinical outcomes and quality of life.

How to practice evidence-based medicine

Convert information need into an answerable question

Tracking down the best evidence

Integrate the evidence with clinical expertise, patient

values and feasibility

Critically appraise the evidence

Evaluate and improve the process for future use

What is expected of the physician

• No greater opportunity, responsibility, or obligation can fall to the lot of a human being than to become a physician.

• In the care of the suffering, he needs technical skill, scientific knowledge, and human understanding.

• He who uses these with courage, with humility, and with wisdom will provide a unique service for his fellow man, and will build an enduring edifice of character within himself.

The patient-physician relationship

• Physicians need to approach patients not as “cases” or “diseases”, but as individuals who is human. Fearful, and hopeful, seeking relief, help and reassurance.

• Tact, sympathy and understanding are expected of physician.

• “If you can not do the things you like to do ， you should like the things you have to do” 。

1 ．进入病房学习前，对照大纲和示教的重点病例复习内科学的相关章节，准备在病例讨论中提出和回答问题；

2 ．进入病房后尽快熟悉重点讨论的病例，争取第一时间采集病史，进行体格检查，考虑相应的诊疗处理措施，以备讨论；

3 ．注重理论联系实际，重点是培养临床思维能力。

七年制床旁教学学习过程中几个需要注意的事项

4 ．尊重患者，对待患者要热情，富有同情心；

5 ．注重与患者及其家属的沟通，注意谈话方式，不刺激患者，对于不能回答的问题应找相应的病房医护人员来解决，不能敷衍了事或简单的回答“不知道”；

6. 体检时动作应轻柔，对危重患者，应事先征得床位医生及患者同意方能进行，必要时由床位医生陪同进行；

 

考核方式：• 床旁示教占 30% ，书面考试占 70% 。• 床旁示教考核由带教老师根据学生表现，从 5 个方面进行打分：纪律及对患者态度、病例讨论时回答问题情况、问病史、体格检查、病史书写等，每个病区评分总分为 5 分，共计 30 分。

• 6周结束时进行书面考试，总分 70 分，其中 20 分左右为与病例讨论及示教相关的病例分析题， 50 分为本学期上的大课内容。

Thank you