暫時性診斷之教學訓練模式評估

為了加強訓練醫學生在詢問病史時，就能應用已有的知識和診斷思考與邏輯，以獲得完整且具有區辨性的病史的能力，本研究以實際個案病歷與自寫病歷兩種方式進行實驗性暫時診斷的教學訓練，並作比較評估。研究對象為以小組輪流到神經科見習的56位六年級醫學生，訓練方式有實際個案病歷之問題導向學習教學，和自寫病歷之討論教學，課前與課後進行無記名的填答評估問卷。下暫時診斷是臨床診斷中最困難的步驟，57%有效回答的同學認為最主要的原因是對疾病的知識不足，只有26.5%的同學提到與診斷思考有關的理由。實際個案病歷教學在整體滿意度、可行性和對診斷思考的助益，均高於自寫病歷教學，而且還獲得高度警惕。本研究顯示實際個案病歷教學，不但可行而且對診斷思考也有助益；雖然學生比較不喜歡自寫病歷教學，但是這兩種方法有其互補作用。

關鍵字

暫時診斷；診斷會談；診斷思考；個案病歷

並列摘要

The clinical diagnosis training course is traditionally and formally implemented in the first or second semester of the fourth year in the Taiwan medical schools. There are no training courses available in diagnostic thinking and, overall, diagnostic thinking is not particularly emphasized during medical training. This study developed, implemented and evaluated two innovative approaches to training in clinical diagnosis with a focus on using available knowledge and diagnostic thinking to formulate a tentative diagnosis based on the case record (case history teaching) and the writing of a case history by the student. In the academic year 2002, 56 senior clerks were divided into six small groups and rotated through the Department of Neurology. A problem-based learning approach was adopted for the case history teaching and discussion was used to teach the creation of a written case history by the student. Before the course, the students were asked anonymously to express their feeling on the difficulties associated with the process of making a tentative diagnosis and they were also asked to give reasons for their answer. At the end of the course, a comparative evaluation of the two methods was made through anonymous responses to a questionnaire. The most difficult step of making a tentative diagnosis was identified as ”giving a tentative diagnosis”. In total, 57% of 49 students suggested that the main reason for this difficulty was a lack of adequate knowledge of the disease. Only 26.5% of them suggested that the difficulty was related to a lack of skill in diagnostic thinking. The students preferred to be taught case histories to the teaching of a self-written case history. This was probably because a lot of time was taken up typing the history and making records during the self-written case history teaching. Regarding the case history teaching, general satisfaction, feasibility, lessons from the case and benefits to the diagnostic thinking were the highly satisfactory items. However, the appropriateness of the case, the extent of the case, and the difficulty of applying diagnostic thinking during a clerkship, were the less satisfactory items. In conclusion, making a tentative diagnosis was considered to be the most difficult step in the process of clinical diagnosis among the senior clerks. Case history teaching is not only highly feasible but also highly beneficial to the learning of diagnostic thinking. Although the students show a lower level of preference for self-written case history teaching, these two strategies are mutually complementary. Developing and implementing the training course for formulating a tentative diagnosis should be considered when reforming the clinical diagnosis curriculum.