重视临床决策,提高临床医学水平

当代临床医学的发展与提高,与基础医学的研究密切相关,与科学技术提供的诊疗装备密切相关。由于现代信息技术的发展迅速,科技情报传递速度很快,以及经济全球化提供的便利快速的物流网络,医学的任何新设备、新药物、新的诊疗方法问世后,很快就能传遍全世界。就我国而言,我国临床医学水平与一些国家的差距,主要不是装备的差距,不是新设备、新药物的差距,而是如何运用医学新技术、新设备、新药物的差距,实际上也就是临床研究思维和临床决策水平的差距。如何通过科学的临床思维,使得我国临床诊疗决策更加科学、高效、实用和经济,实为提高我国临…     

医院发展临床医学高技术的哲学思考

目前,某些医院发展临床医学高技术存在的主要问题为:一是选择的医学高技术与医院的现实发展不符,不是造成医学技术的浪费,就是造成医院开发资源的浪费;二是引进的高技术过分依赖仪器或设备的作用,而忽视了人的力量,一旦设备淘汰就丧失了技术发展的根本;三是对高技术的发展前景缺乏预见性或系统性分析,使技术或资源的可持续发展受限。从这些基本点出发,本文结合我院情况,仅就临床医学发展高技术作一哲学的思考。1　有的放矢,选择发展高技术建国至今,我国医学事业发展虽然取得了很大的进步,但整体水平与发达国家相比还存在一定的差距,而医院要…     

专科分会组织建设要为学科发展服务

1 临床医学发展步入"数字医学"时代 随着临床医学的迅速发展,越来越多的新技术介入到医学领域,临床应用数字技术产品以及通过基于网络环境下的数字医学技术平台为医生提供更准确、更直观的诊疗依据.     

对中药复方不同提取部位的相关研究之思考

1临床医学发展步入“数字医学”时代 随着临床医学的迅速发展，越来越多的新技术介入到医学领域，临床应用数字技术产品以及通过基于网络环境下的数字医学技术平台为医生提供更准确、更直观的诊疗依据。数字医学技术的临床应用带来了一系列的变革，如催生新的学科体制与相应管理系统的建立，实现网络环境下影像学软诊断，为临床医学信息的共享、挖掘、分析与增效、创新知识提供现代技术条件等等。     

循证医学与医学创新的关系

循证医学 (ｅｖｉｄｅｎｃｅ -ｂａｓｅｄｍｅｄｉｃｉｎｅ ,ＥＢＭ )是近年来国内外倡导的新医学模式 ,它改变了传统的以经验为基础的临床医学模式 (即经验医学 ,Ｅｘｐｅ ｒｉｅｎｃｅｄ -ＢａｓｅｄＭｅｄｉｃｉｎｅ) ,提倡准确地、公正地和自觉地应用现在最好的证据为每个病人提供诊疗服务[1] 。医学创新 (ＭｅｄｉｃａｌＩｎｎｏｖａｔｉｏｎ)是医学发展的源泉 ,并不断地创造新的先进的诊断和治疗方法 ,为临床医学提供可靠的证据。循证医学与医学创新相互联系 ,相互促进 ,共同发展。1　医学创新是循证医学发展的动力循证医学的本质就是…     

循证医学的道德内涵

目前 ,关于循证医学的评介和研究 ,基本停留在临床诊疗的水平上 ,至多是处在临床医学的范围内。事实上 ,循证医学之于当代医学发展的作用并不局限于临床诊疗、临床医学[1] 。从医学伦理学的角度考察 ,循证医学的产生和发展有着鲜明、深刻的道德特征 ,反映了当代医学道德进步。可以预言 ,伴随着循证医学的深入发展、循证医学概念的普及、循证医学基本原则的贯彻落实、循证医学方法的广泛应用 ,它必将对医学道德进步、对当代医学道德本质的实现起到有力的保障和推动作用。1　循证医学体现了当代医学对精益求精的追求追求精益求精是医学道德本…     

循证医学的价值与当前存在的几个误区

循证医学本身是西方现代科学、医学和统计学三者结合起来以后在临床医学领域创建的新兴概念.最开始提出这个概念的是流行病学专家,距今大概有30多年.在我国循证医学兴起的比较晚.从本质上讲,它并不是基于对个体疾病诊疗的思考,而是一种科学的、高层面的、自上而下的一种临床科学思维,而是基于临床科学的思考[1-2].     

为临床决策的科学化而努力

当今,我国的临床医学实践正面临着深刻的挑战.摆在我们面前的现实是:一方面,医学科学的快速发展,为许多疾病的诊断和治疗提供了多种选择,为诊疗最优化提供了广阔的空间;另一方面,我们在应用医学发展提供的科学成果为病人诊治时,由于医生的学术基础、临床经验、诊疗决策、治疗动机的差异,其效果差别极大.辽宁省抗癌协会最近的一项抽样调查表明,该省癌症的规范化治疗率仅为32.46%,其中A级医院不规范治疗为53.21%,B级医院不规范治疗为66.49%,C级医院不规范治疗高达96.69%.     

为临床决策的科学化而努力

当今，我国的临床医学实践正面临着深刻的挑战。摆在我们面前的现实是：一方面，医学科学的快速发展，为许多疾病的诊断和治疗提供了多种选择，为诊疗最优化提供了广阔的空间；另一方面，我们在应用医学发展提供的科学成果为病人诊治时，由于医生的学术基础、临床经验、诊疗决策、治疗动机的差异，其效果差别极大。辽宁省抗癌协会最近的一项抽样调查表明，该省癌症的规范化治疗率仅为32．46％，     

循证医学与临床医学教育

循证医学 (Ｅｖｉｄｅｎｃｅ -ｂａｓｅｄＭｅｄｉｃｉｎｅ ,ＥＢＭ)是临床流行病学和现代信息学与临床医学结合的典范 ,是近年来国际上临床医学领域迅速发展起来的新学科。国际著名的临床流行病学家ＤａｖｉｄＳａｃｋｅｔｔ将ＥＢＭ定义为“谨慎地、明确地、明智地应用目前所获得的最佳研究证据 (资料 )来确定患者的治疗方案”[1] 。循证医学的核心思想是 :医疗决策应尽量以客观研究结果为依据 ,即在个人临床经验的基础上 ,从日新月异的医学科学的发展中获取最新、论证强度最高的证据 ,以不断地提高临床诊疗水平。其实质是一个新式高效的…     

Clinical Equipoise and Adaptive Clinical Trials

Ethically permissible clinical trials must not expose subjects to risks that are unreasonable in relation to anticipated benefits. In the research ethics literature, this moral requirement is typically understood in one of two different ways: (1) as requiring the existence of a state of clinical equipoise, meaning a state of honest, professional disagreement among the community of experts about the preferred treatment; or (2) as requiring an equilibrium between individual and collective ethics. It has been maintained that this second interpretation makes it mandatory to minimize the number of patients receiving the treatment that will eventually be shown to be inferior by the trial. This requirement has led to the development of adaptive trials, i.e., trials in which treatment allocation is determined by data accumulated during interim analysis. Many statisticians argue that in some circumstances—typically with potentially high benefits, as in the much discussed ECMO trial—adaptive design is the only ethically permissible experimental design. Nevertheless, some proponents of clinical equipoise argue that adaptive trials are neither ethically required nor permissible. More specifically, they argue that clinical trials using adaptive designs fail to meet the moral requirement of clinical equipoise, since these trials presuppose an epistemic state that is incompatible with a physician’s duty of care to her subjects. This paper emphasizes that the debate is to a large extent resting on an epistemological confusion. Specifically, I argue that this response conflates two different conceptions of statistical evidence (i.e., frequentist and Bayesian), and that recognizing this distinction elucidates an epistemological framework in which adaptive trials are both consistent with and recommended by the moral requirement of clinical equipoise.

     

Clinical Judgment and Clinical Significance in Psychotherapy Practice

The use of outcome measurement in psychotherapy practice is briefly discussed, as is Jacobson and Truax’s (J Consult Clin Psychol 59:12–19, 1991) conception of clinically significant change. A more flexible and user friendly application of clinically significant change compatible with clinical judgment is proposed for psychotherapy practice. Examples are given and a free Windows program is described for computing RC and estimating the probability associated with it.     

Clinical Commentary

This commentary is slightly different from previous ones in that the clinical work presented took place some 20 years ago. This gave an opportunity, for those commentators who wished to, to take up how they think the work of a child psychotherapist might have changed in the intervening years.     

Clinical Commentary

Abstract

This paper is the narrative of a first-time father with a son born seven weeks early by Caesarean section. Against the anxiety and trauma of his infant's birth and his wife's illness, another inner darker drama is being relived. Michael shows all the wounds of a battered child. He asks two awesome questions - Will I be to my son as my father was to me? Will my son be to me as I was to my father? Fearful and at first unvoiced questions, the developing interviews gave them a voice. We respected Michael's sharing of the early and fearful days and nights when his infant first came home. We sometimes found it hard to empathize with his running away to hide in work, until we understood what he was hiding from. Most poignant was his struggle with his anger and hurt with his father and his desire to understand, ‘Why?’, so that he would not be like this to his son. We saw a sensitive revelation of life being born inside him anew, as he made contact with his real infant and his psychic infant within. Of particular interest was the therapeutic use of the research interview space and the interviewer.