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研修医から見た新臨床研修制度(6/11講演記録)

6/11に地域医療研究会の講演会【新臨床研修制度を考える】で発表した内容を、簡単にまとめてみたので、アップします。

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研修医から見た新臨床研修制度
  東京医科歯科大学所属・三島社会保険病院研修医 小池宙

 ひとりの研修医として研修医や医学生の中にいると、新臨床制度についての文句が、聞こえてくる。
 始めに明らかにしておきたいが、私自身は現在の卒後臨床研修制度は非常にありがたいと思っている。まず、マッチングは、井の中の蛙が次世代の井の中の蛙を育てていたような教育システムに、風穴を開けた。「研修医に選ばれる病院」となるためには、「大海」に通用するような教育内容を求められ、またその内容が他の病院の教育内容に刺激を与えていると、見ていて思う。また、医学生の意識にも影響を与えた。ある医学生が口にしていた。「医者になれば就職活動しなくてもいいと思っていたからこの道にきたのに…」と。就職活動は、様々なことを学生に教えてくれる。漠然と医師の道に進んでいた学生たちに対する、いい意味での関所となっているだろう。
 また研修医をしていて思うのは、各科の勧誘の綱引きに巻き込まれないで広く医師としての基本を身につけられることが、ありがたい。専門家間の議論を、どちらの立場にも立たない視点で聞かせていただけるのも、ありがたい。個人的にはそう思っている。
 しかし、現場の研修医・医学生からは、不満の声がたくさん聞こえてくるのもまた現実としてある。曰く、

・各病院の本音と建前がわからない(使いつぶす労働力なのか教育の対象なのか)
・いいと言われるブランドのある病院が本当にいい病院なのかわからない
・短期間しかいないマイナーにいるとテンションが下がる
・自分が実際に受けている研修内容が正しいのか正しくないのか、確信を持てない

などがある。
 それらの根本には、今の新卒後臨床研修には欠けているものが三つあると、私は考えた。「Evidence」「Standard」「Outcome」の三つである。
 Evidence、つまり、以前の制度から現行の制度に変わってどのような成果が出ているのか分からないし、各病院での研修の真実も分からない。そのため、考えれば考えるほど根拠を持って道を選択できず、不満がたまる。
 Standard、つまり、一般的な研修内容(日々の生活など)が分からないし、他の病院でどんな研修が行われているのかが分からない。そのため、現状に安心できないし、逆に現状にあせることもできない。不安ばかりがつのる。
 Outcome、つまり、スーパーローテート、特にマイナーを回ったらどんな成果が出るか分からないし、地域医療研修の意味も分からない(地域医療は、保健所の力の入れ方の違いなどがあり、環境によって経験できる内容の質がまったく違うこともあり、不満がたまりやすい)。具体的にどんな医師をこの制度はつくりたいのか受け手にはなかなか分からないし、2年間が終わったら結局どんな能力が身につくのか、分からない。3年目に新たな道を選択しなければいけないこともあり、見えない未来に向かって不安がつのる。

 今、医学教育の結果、医学生たちはEvidence、Standard、Outcomeを意識するようになった。それらを使いこなし、より良いものを導き出す基本も、少なくない研修医と医学生が身につけていると思われる。しかし、肝心の医学教育や研修制度に、それらの三要素がない。それらの三要素を導くためのDataがない。そのため、よりよいものを導き出すということを、現場の研修医や医学生ができないのである。
 繰り返すが、新臨床研修制度は、以前と比較しすばらしいものだと私は思う。しかし、その本来到達できるであろう世界とDataがなくちぐはぐな状況の間で不満と不安ばかりがつのる現状は、どうにか対処するべきだと思うのである。

 補足になるが、そういったDataを厚生労働省や病院に任せきることは無責任だと思い、私自身も仲間達と、記録をつけ始めた(例:「とある研修医の日々」)。調査能力も処理能力も私達のレベルでは限りはあるが、それでも、現場の人間達にしか集められないDataを集め、現場の人間から、より良いものを提案していくことをしてみたいと思っている。もしも可能であればぜひ、御支援や参加等、していただけると幸いです。

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