東大ノート(医学教育)
かなり、不完全燃焼な講義でした…
まあ、おいらが医学教育について口を開いたら爆弾発言多すぎるから、市村さんも俺を指名しなかったのかもな…
---------
1124 医学教育
●Inui先生
医学教育の中で、プロフェショナリズムを教育しているか、調査した
コースとして講義しているところはすくなかったが、
講義の一環としてプロフェッションを教えているところはあった
これを教えることが必要要件とされている
プロとしての属性を測定するという分野でも…
すばらしい調査結果が!
メディカルスクール学生中の行動で
医療過誤訴訟をうけるかどうかを予測できる!
メディカルスクール時代に教授や学生とうまくコミュニケーションが取れないのであれば、医師になってもコミュニケーションはとれない
それが、訴訟につながる
アメリカで、専門医となるための専門機関がある
生涯学習をそのようなかたちで推進している
プロフェッショナルの価値観の推進も行っている
なぜ盛んにプロフェッショナリズムが取り扱われているのか?
これまではBiomedicalの医師が、癒す人としての位置を独占してきた
が、代替医療が、癒しの役割の一部を担うようになってきた
過去に、生物医学の分野は、技術者集団のギルド。制限があった
が、ナースの役割のように、医師による独占分野ではなくなってきた
社会医学の分野 生物医学が公益を担っていた
サービスを社会のために提供していると思われている
が、多くの人がはらうコストが高くなってきている
医師にそれだけお金をつぎ込むことに疑問が起きてきている
科学の繁栄
技術の繁栄
しかし、だからこその危険
ひととの関係という医学の基本も忘れてはいけない
専門的職業である医師
特別な高いステータスを求めている
しかし、
「プロフェッショナル」
は高いステータスを必ずしも意味していない
「対価を得る」という意味を持つだけだった時代もある
50年前は、
高い教育水準・規制が少ない
しかし、同業者で規制がある
という時代があった
最近は、分野に優れているというだけでプロフェッショナルと呼ばれるようになってきた
プロフェッショナルの意味が価値が、下がってきている
例)プロのペンキ屋・水道工などなど…
医学の内部でもプロについて議論されている
知識・技能(コミュニケーションなど)・態度(他者を尊敬するなど)・献身的な態度(現場を離れても、公害などなど健康を向上させるための行動をする)
様々な調査
だが、なぜ見解がにてるのか?
目指しているもの(倫理)が似ているからでは?
医学の分野では、科学者として 「真実」に高い重要性を置く
→EBM の重要視
しかし、それは理想
現実には、uncertainty
確率論の数字はでる。統計的調査によって。しかし、
「自分の場合はどうなんでしょう?」とひとりの患者さんに言われたとき、
やはり不確実
AのほうがBより85%の確率でいいとしても、
その患者が85%にはいるか15%に入るか分からない
現実には不確実性に悩んでいる。
なんとかバランスをとろうと苦労している
メディカルスクールで、
理想を教えながらも、現実とのバランスをなんとかとろうとしている
その不一致のなか、どのような教育をすればよいのか
状況についての調査
あまり良い結果が得られていないと出てきた…
高い意思ではいってきても、テストに受かるという最小限のことしか考えなくなる
オープンな、人助けをしたい、という考え方があっても、
教育を受けるうちに、冷淡な考え方に変わっていく
一生懸命ノートを最初はとっていても、
最後は、教師の態度・言動を見ている
現実とリアルとの間の隠されたカリキュラムを受けている
いくつかのメディカルスクールにて。
入学当時は利他的であっても、卒業時はシニカルに。
理想と現実が違うことをしって、そう変わっていく。
そこで、北米ではプロの価値観について大きく研究されている!
どのようにすれば冷笑的にならないのか。
できること。
学生に「どう感じたのか」問いかけること
その答えに耳を傾ける
議論をする
われわれの観点と、学生の観点は違うかもしれない
それを、議論する
思慮深さも必要
患者と話すので5分しかとれない
しかし学生がこれをどのように捕らえるのか、きちんと認識しないといけない
二つの格言
「危害を及ぼすな」
「沈黙をするな」
人類学者によると、教えていることと違うことをしてしまうと
沈黙してしまうという研究。
たとえば患者と話している時間が短いことの説明をしていない
こんなとき、きちんと説明しなければいけない!
患者さんとのコミュニケーションについての取り組み
教師・患者・学生がそろったなかで、患者さんの意見も
交えて議論をしたり
プロとい価値観を、
学生もわれわれも持つための、努力
◆質問◆
●10数年前のアメリカの経験から。
アメリカの医師は非常にお金持ち。
保険に入っていない、非常にむずかしい手術を、医師はやらなかった
レジデントがやっていた
これは大問題!
お金と権力と尊敬を、一緒にはとれないという日本の文化
アメリカではその三つをとれる変な国
そんな中で、こんなことしても変なことになる
→同意する!
貪欲・物欲 と 利他的、を対比させたのはその現実があるため。
しかしすべてのDrではない
プライマリーケア医はそうではない
外科的Drは、高い収入が上位10%のみ。
患者とコミュニケーションをとるDrの収入は少ない
コミュニケーション技術に対価が払われないのが問題である
●日本では医学教育は地位が低い
理由:評価が難しい!
臨床であれば、症例数・術後評価
研究であれば、ペーパー
アメリカでは、どのように教師を評価している?
教育専任の人員はいるのか?
→学生レポート、研修医レポートが、もっとも良い測定法だと思う
測定方法の検証も行われている
同僚の教師による評価と、上の二つを比較した
その結果、三つは相関関係が高かった
このような測定・評価を行っている大学では、評価の記録と
科学的測定を行っている
教師・臨床医、などの道の中で、
効果的な仕事をしているのか?
教育に使う材料も、評価されたものを使うようになってきている
www.aamc.orgでも、教材について、教師に無料で提供されている
●西野先生 (亀田)
医学教育
…卒後教育について話す
(略歴)
徳島大学 医局制度8年間 卒後研修
メイヨー 神経内科
向こうで大切なもの 「SELF」
strucured
equal
l
free
亀田
87年からの卒後教育の歴史
<アメリカ式卒後研修の導入>
・アメリカ人指導医の導入
・アメリカで研修を受けた日本人指導医
・研修医の海外派遣
アメリカ人指導医導入の功罪
長: 教育専任の存在(医療ができないから)
グローバルスタンダード
指導医・プロとしてのロールモデル
アメリカ留学希望者のメンター
短: インパクトが研修医に限定
コストがかかる
しかし、思わぬ効果
92年からアメリカ人医師を導入したら、研修応募者の増加!!
アメリカで研修を受けた日本人医師
+ (アメリカ人と同じ)
− (アメリカ人と同じ)
日本育ちの医師からの排斥
…アメリカ帰りの多くの医師は実力を発揮していない
研修医の留学
若い医者は感性が豊かなので、ほうりだすとインパクトが
「アメリカ式研修導入はプロとしての医師育成に役立つか?」
効果はあるが、限界もある
工夫が必要
人づくりには時間を要する!!!!
構造・研修の授けること
◆質問◆
●日本では研修医が過労で死亡
遺族が勝った
どちらも経験した西田先生からみて、アメリカでの対策は?
→過労度については、日米あまり差はない
が、アメリカのほうがはやく手を打った
週80時間までという制限(40時間でなく!)
それまで110時間働いていた
亀田でも、現実には110時間くらい働いていると思う
●米国人医師の専門は?
→心臓血管・感染症・家庭医
●どんな観点で選んだ?
→応募があれば、とる
●排斥
アメリカに行くこと事態がバイアスになると思うが。
向こうでの教育が原因?
具体的に何が合わなかった?
→個人の要素もある
日本とアメリカでは治療アプローチが全然違う→関係悪くなる
●医局制度でも起きている問題なのか?
→そうだろう
●卒後研修でカンボジアに1ヶ月?
プライマリケアもできない医者をおくっていいの?
→見学だけです
●日本の僻地に送っては?
●卒後研修が終わったあと、残らないだろう?
亀田をでた先生いろいろ動いているだろう
→希望者は残る
全員は残らない
動くことは、いいことだ。
◆北村聖 (東大)
(プリント充実)
今、医学教育は大きく改革が進んでいる
<一番かけているもの>
「個人で考えることをしていない」
「教えられたことを吸収しているだけ」
◆質問
●患者さんを多様に診る視点がない
ナラティブを医学教育にも
被害者や患者団体をいれることもしてきているが
患者全体像を学ぶ機会はこれから増えるのか
→たとば肝硬変などでも、個別性が必要
「最高の医療を」はまちがえ
「個々の患者に最適な医療を」が正しい
EBMを利用して、個人に対して対応していかないと
●最低限の知識を得てもらうために
6年より多い時間を与えることは考えているか?
→8年10年にしたら…は研修の義務化がそのようなもの
ただ、手を動かしながらでしか学べないものをかくじゅうかした
●教えれるひとはどれだけいるのか
→各大学が、一番熱意を持っている
●朝8時から一時間カンファレンスでて、4時までなんにもなかった
しかも、行ってみたら講義がなかった…
研究と臨床とでみなさんお忙しいので、なかなか教えてもらえない
どうしたら教育の比重を上げられる?
→5年生は、ベッドサイドで教育を受ける
教えるほうとしては、次から次へと学生がくる
課題の適正化をチェックして、フリーな時間を多くすればいいのだけれど、
システマティックでないから「ほっとかれた」になる
●理科3類の廃止をすべき!
教養課程であれだけ遊ぶ、2年間何もしない
これをなおせば東大はとてもよくなるだろう!
→理3は、対して努力しなくても医学部に入れる
教養の2年間は、いかにうまく、やる気なくして潜り抜けていくか、だ。
だが逆に、点数にきゅうきゅうとしているのも…
教養学部改革
理3は点数が悪いと落ちるシステムにした
→した3人は落ちるシステムにした
◇偏差値高すぎる…
◆市村
卒前と卒後がオーバーラップして無駄なところがあるだろう
韓国より遅れている
●「医学教育のデザイン」
文部科学省も、医療の専門家でもない
足かせが…
<<医学教育省>>を作ってもいいのではないか?
●産業界の部分でも、一般的にあると思う
医学教育省だけつくってもいいのか?
文部科学省と厚生労働省の連携があるべきでは?
経済産業省も連携していくべきだと思う
●その考えは非常に良く分かる
逆に、かんじゃさんの人権意識が高い
学生が注射したくても、たいてい断られる
ライセンスのありなしで、やれることが明らかに違う
省庁が一元化することは…
いずれにせよ、連絡をよくすることは大賛成
◆市村
網と方法を覚えるべし
…アメリカの医学教育では、責任をもって学生がかなりできる
考えてできる
日本では責任の問題が…
能動的に動けない
網を持たされてもなんのためにつかうのかわからない!!!
生涯教育の姿勢を在学中に身につけられない
●医療の教育
患者の権利のことは教えられている(ヘルシンキ宣言など)
治験にエントリーされる患者さんから、相談される
エントリーするときに、医師の言葉がめちゃくちゃ
◆北村
医師国家試験委員
医療倫理の問題は出ている
が、情けない…
安楽死を扱っているのは、以下の森鴎外の小説のどれか?
…かなり問題
講習会を聞かないと、臨床試験はできないことになっている
若い先生はむしろ慎重すぎる
◆Inui
→インフォームドコンセントのあり方の問題
理想と現実の違い
これがおすすめです、と Drが説得するという傾向
学生時代にICをならっても、それは違うと思ってします
教授陣は時間がないので説得に走るが、
学生は、ICの重要性をわかっている
学生がICをするという方法もあるだろう
◇医学教育における網と方法の選び方を間違えていないか?
注射する、とかの「お医者さんごっこ」をしたがるのは、問題があると思う
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