第103课 现代外科手术的培训学说（Modern surgical training theory...

随着现代医疗水平的不断创新，外科在诊疗过程的关键性也越是重要，而在外科医生的培训也必将加速规范化及高效性。外科技术的教育一直遵循着（see one, do one, teach one）的理念，一百多年前 Halsted 医生在约翰霍普金斯医院创建了沿用至今的《现代美国住院医师培训制度》，同样也是基于在住院医师期间大量积累手术量并借此掌握甚至精通某项技术的方法学。熟能生巧肯定是正确的，但是问题是，你在哪儿练、怎么练、怎么知道你练成了？

With the constant innovation of modern medical treatment, surgical critical is the more important in the diagnosis and treatment process, and the surgeon training will accelerate the standardization and high efficiency. Education has always been following the surgical technique (see one, do one, teach one), more than one hundred years ago Halsted created a doctor at Johns Hopkins hospital in use today's 《modern American residency training system》, is also based on abundant accumulation during the period of residency and he proficient even a technology methodology. Practice makes perfect must be correct, but the question is, where do you practice, practice, how do you know how are you getting there?

根据我个人的见闻——或许你也会跟我有同样的看法：传统的外科手术技能的提高，都是在人身上练的。非医疗专业的朋友看到此请不要摔桌子、不要断章取义，这可能不是你想象的那样。从见习、实习开始，我们就会有机会接触到临床的一些操作、观摩并参加一些手术，一开始都是看。随着知识的储备和对操作的逐渐熟悉，在合适的机会，上级大夫会让你逐渐升级：比如说开放性手术的时候，从二助到一助，再到让你动手从简单的操作开始逐渐加深难度。这个时候，上级大夫作为手术的负责人，会一直在旁监督你的一举一动，如果有不当或者任何可能危害患者安全的行为，就会及时制止；通过这样练习的积累，你就会逐渐掌握某项外科技术。当上级大夫觉得你练的不错了，能足够安全的完成该项操作的时候，你就会被认为是学成了。

According to my personal experiences, perhaps you will also have the same opinion with me: the improvement of the traditional surgical skills, are in practice of the human body. Non-medical professional friends see this please don't fall off the table, don't be taken out of context, this may not be as much as you'd think. Starting from the practice, practice, and we will have the opportunity to come into contact with some of the clinical operation, observe and participate in some of the surgery, the start is to look at. As the reserves of knowledge and familiarity with the operation gradually, in the right opportunity, the higher the doctor will give you a gradual upgrade: such as open surgery, from the second to help, to let you to start with simple operation becomes more difficult. This time, the superior doctor as head of the operation, has been to supervise your movements, if there is improper or any behavior that may be to endanger the safety of patients, will stop in time; Through the accumulation of this exercise, you will gradually learn a surgical technique. When the superior doctor think you practice good, can secure enough to complete the operation, you will be regarded as well.

可是这种传统的师傅带徒弟的训练方式在现在并不是那么适合了。

But the traditional way of the master train an apprentice training in is not suitable for now.

你觉得美国的医疗技术怎么样？据今年 5 月份发表在《British Medical Journal》的一篇文章，2013 年美国有 251454 例病患的死亡源于医疗差错，该死亡人数分别是车祸致死和枪械致死人数的 7.4 倍。这使得医疗差错成为了美国致死原因排名的第三位，仅次于心血管疾病和恶性肿瘤。在国内，我只看到了《京华时报》引中国红十字会的一篇报道，大意是中国每年因为医疗差错死亡的人数大概是 400000——然而我并没有看到文献上的数据，无法评估其可靠性。

What do you think of American medical technology? According to may this year, published in the 《British Medical Journal》 'an article, in the United States, there are 251454 cases of 2013 patients of death due to Medical error, the death toll is respectively 7.4 times the amount of people died from the car accident deaths and the gun. This makes medical errors in the U.S. death ranked third, behind cardiovascular disease and malignant tumor. At home, I only saw the Beijing times quoted a report in the China Red Cross, the effect is the number of deaths every year in China because of medical errors is about 400000 - I did not see the data on the literature, however, unable to assess its reliability.

如何保障患者安全始终是第一位的。所以，我们先从患者安全的角度来说。举个例子吧。传统的外科技术传授大多发生在手术室，开始的时候上级大夫大多是手持钳子站在你旁边或对面，眈眈地盯着术野或者正在流汗的你，一旦出现异常或存在潜在的风险的举动，他就会及时喝止你或用止血钳敲开你的器械。随着这几十年微创技术、腔内技术的发展，手术的操作越来越趋向于更少的人完成——特别是腔内技术，只有一套器械或者镜子在患者体内操作，这个时候上级大夫及时在旁边，也可能会存在无法及时制止你手上的操作，进而可能会危及患者安全（现在机器人手术系统的两个工作台倒是给上级大夫提供了随时制止你的机会）。再加上内镜操作的时候我们某些可以依靠的感观的消失：比如触觉反馈、3D 视觉等等，都有可能会增加我们对安全认知不足的风险。更何况，如今的医患关系……上级大夫放手之前，都会心里多掂量掂量……

How to ensure patient safety is always first. So, we first from the point of view of patient safety. Take, for example. Traditional surgical techniques taught mostly occur in the operating room, at the start of the superior doctors mostly holding forceps stand next to you or the opposite, ground stare at operation field or you are sweating, once appear abnormal or potential risk, he will stop you in time or use the hemostatic forceps knock on your device. As the decades the development of minimally invasive technique, cavity, surgical operation is more and more people tend to be less complete - especially cavity technology, only a set of equipment or in front of the mirror in the patients with operation, this time the superior timely beside, doctor may also fail to stop the operation in your hand, and then may endanger the patient safety (now the robotic surgery system two table is offered a superior doctor at any time to stop your chance). When combined with endoscopic operation we can rely on some of the disappearance of the senses, such as tactile feedback, 3 d vision, etc., have may increase our risk of insufficient safety cognition. What's more, the doctor-patient relationship now... The superior doctor before letting go, will weigh was great...

第二，上手机会不足。虽然现在大家都在抱怨住院医师培训制度，但是即便这样长时间的锻炼，仍然不足很多住院医师对于某项技术的熟悉和掌握，因为：每个科室的轮转时间有限、各组各科室病种差异大、练的大夫多、病房事情杂、新器械造价高维护费用贵……总之，就是各种原因造成的你上手机会少，甚至陷入了没机会动手、不允许动手、不敢动手，这样的循环；何来熟能生巧？

Second, those opportunities. Although now everyone is complaining about residency training system, but even this exercise for a long period of time, still less than many resident for a technology familiar with and master, because: each department the cycle time is limited, each group of large difference of disease, the practice department doctor, complex, a new instrument of ward things cost more high maintenance cost expensive... In a word, is all sorts of reasons cause the less chance you get started, even in a no chance to begin, not allowed to start work, did not dare to begin, the cycle; No practice makes perfect?

第三，还是关于新技术。各种新技术的出现，常常伴有更长或者更陡峭的学习曲线。在学习曲线初期是容易犯错的时期，要练习的人这么多、术式这么多，你有多大的信心在上级大夫的指导下在患者的身上完成学习曲线？更何况，有些时候，你的上级大夫，也有可能正在学习曲线上爬坡……他还没练成，怎么指导你？

The third, or about the new technology. The emergence of various new technology, often accompanied by longer or more steep learning curve. At the beginning of the learning curve is easy to make mistakes, to practice so much, so much surgery, you have much confidence in the superior doctor in patients completed under the guidance of the learning curve? What's more, in some cases, your supervisor, doctor might also is climbing on the learning curve... He didn't practice, how to guide you?

第四，关于如何评估。什么时候可以独立做某项操作了？什么时候能够独当一面了？我想，目前除了知识性的考试之外，更多的是依靠上级大夫／考官的主观评估。根据他们之前制定的标准，他们说行你就行。主观的评估：哎……

Fourth, about how to evaluate. When can the independent to do an action? When can acquire? I think, in addition to test knowledge at present, more is relying on the superior doctor/examiner's subjective evaluation. According to their standards before, they say you will do. Subjective evaluation: ah...

仿真模拟培训或许是一个比较靠谱的解决方案。医疗仿真模拟设备最大的优势是其可提供一个可以多次重复操作的、不危及病患安全的、通常还是可以量化评估受训者技能水平的平台。需要首先说明的是，仿真模拟教学，并不是也不会替代传统的外科技术教学，而是旨在更安全更有效的增强或者完善传统的教学方式。

Simulation training is perhaps a comparison of the solution. Medical simulation equipment is the biggest advantage of its can provide a can repeat the operation, do not endanger the safety of patients, usually can be quantitative evaluation platform of trainees skill levels. Need to first, simulation teaching, is not also won't replace traditional surgical technique teaching, but to a safe and more effective to enhance or improve the traditional way of teaching

有了仿真模拟设备还是不够的，仿真模拟设备必须配以精心设计和验证过的课程才能充分发挥其效能。单纯在模拟设备上训练出的熟练的技能可能会包含只适用于该模拟器且模拟设备自带评估系统无法辨识的错误。仿真模拟的课程一般包括理论授课和实际操作；课程内容包括技巧类技能（technical skills）和非技巧类技能（non-technical skills）。技巧类技能大家都比较熟悉了，切开、分离、缝合、打结等等；非技巧类技能包括沟通交流、团队合作、领导意识、临床决策、批判思维等。仿真模拟培训不仅可以优化新手对于技术的学习和掌握，也可以让学员借此保持技术的熟练度、并精益求精；不仅限于临床技能操作的学习，更可以拓展到临床医疗工作的各个方面。关于前文中提到的医疗差错，配以适当课程的仿真模拟教学和培训，可以让受训者身临其境并且相对安全地体验如何识辨差错、差错产生的原因、如何避免产生差错以及怎样从差错中更好的恢复。

A simulation equipment is not enough, simulation equipment must match with a careful design and validation of course can give full play to its effectiveness. Purely on simulation equipment training of skilled might contain only applies to the simulator and analog devices bring evaluation system can't identify the error. Simulation of course generally includes theoretical teaching and practical operation; Course content includes skills class skills (technical skills) and non skills class skills (non - technical skills). Skills class skills, everybody is familiar with the incision, separation, suture knot, and so on; The skill class skills include communication, teamwork and leadership consciousness, clinical decision making, critical thinking, etc. Simulation training can not only optimize the novice for learning and mastering technology, also can let students to keep technical proficiency, and keep improving; Not only in clinical skills learning operation, more can be extended to all aspects of the clinical medical work. Before about medical errors mentioned in the article, match with the appropriate course of simulation teaching and training, can let the trainee immersive and relatively safe experience how to distinguish the mistakes, the causes of errors, how to avoid mistakes and how to better recover from errors.

希望跟大家分享这个不算新的外科技术学习的理念，共同改善患者安全和医疗质量，同时、更有效的学习我们所必须的外科。

Wish to share with you this is not a new surgical technique of learning concept, to improve patient safety and medical quality, at the same time, more effective learning we needed surgery.

医学博士专栏

第三期：来自伍尔夫医生的建议之保护孩子的生活环境

孩子有时候极易受到环境污染的伤害，比如食品中的农药残留物，靠近或建在有毒废物垃圾场上的操场，学校天花板瓷砖暴露出来的石棉，水的铅污染和砷污染，空气中弥漫的二手烟，户外空气污染以及住宅内释放的氡气。

Sometimes children are highly susceptible to environmental pollution damage, such as the pesticide residues in food, built near or on the toxic waste garbage field playground, school exposed ceiling tile asbestos, lead and arsenic pollution of water, in the air of second-hand smoke, outdoor air pollution, and the house of radon release.

孩子接触环境中有毒物质的方式和成人不同，因为孩子比成人呼吸速度要快，呼吸空气的范围更接近地面，也更容易接触并吸入户外灰尘（比如：通过孩子经常做出的从手到嘴的动作），他们与成人吃的食物也不一样，也会和成人用不同的方式代谢这些特定的有毒物质。

Children and adult exposure to toxic substances in the environment way is different, because the child breathe faster than for adults, the scope of the breathing air is more close to the ground, it will be easier to contact and breathing dust outdoor (for example, from a child's often make from hand to mouth movements), with their adult eat food is different also, will and adult metabolism of these specific toxic substances in different ways.

你应该和儿科医生谈一谈，确定下你的孩子是不是有可能接触任何一种上述污染。如果有，应该给孩子做些测试，以便确定孩子是不是已经遭受到污染的危害。如果答案是肯定的，那么家长和儿科医生应该商量下这种污染现在有没有或者将来会不会给孩子带来健康上的危害。

You should talk to a pediatrician, sure that your children may contact any kind of the pollution. If so, should give the child do some test, to determine if child has suffered the harm of pollution. If the answer is yes, then parents and pediatricians should discuss with this pollution have now or in the future will bring to children health hazards.

家长还应该从儿科医生那里了解如何处理当前与毒素有关的健康问题，以及如何尽可能让孩子在未来避免接触有毒环境

Parents should also know how to deal with the current from a pediatrician health problems related to the toxin, and how to make children avoid exposure to toxic environment in the future