以症狀為基礎之病態生理學課程的評估

病態生理學是銜接基礎醫學進入臨床醫學十分重要的課程，有助於醫學生臨床診斷能力的提升，國內醫學教育卻一直都不重視。本研究初步評估在93學年度下學期開設的症狀病態生理學選修課程，有9位四年級選修學生為實驗組，對照組有6位未選課的四年級學生與12位六年級學生。課程採用適合成人學習的多元化上課方式，課題為最常見的症狀，內容是由臨床症狀與病程出發，探討相關的病態生理機制，以思考暫時診斷與鑑別診斷。學期末有課程問卷評估，與兩個臨床個案的能力測驗。實驗組個案一的成績優於對照組；六年級對照組個案二的得分高於四年級的實驗組與對照組；個案一比個案二具有區辨性，但是未達統計學上有意義的差異。選課的同學們不但認同本課程的需要性與可行性，而且認為能夠促進學習與討論的興趣，也獲得優良的學習效果，了解學習的缺失，從而知道如何自學。此外，對同步進行的臨床診斷學的學習，有正面的學習行為效果。初步評估結果顯示本課程的可行性，值得進一步研究其短期與長期對臨床診斷能力的效果。

關鍵字

症狀；病態生理學；臨床診斷學；成人學習

並列摘要

Both inadequate training and a lack of teaching of diagnostic reasoning contribute to the poor performance of medical students when history taking, making a physical examination and giving tentative diagnosis. We developed and implemented an experimental course of symptom-based pathophysiology that included logical thinking, and, using this, we evaluated the feasibility of this approach as part of clinical diagnosis supplementary teaching. This elective course was open to the fourth year medical students in the second semester of the 2004 academic year. The experimental group was composed of nine students and two control groups were composed of six students from the same class and twelve sixth year students. The content of the course consisted of the most common symptoms when initiating discussion about related pathophysiological mechanisms. Various teaching strategies with an emphasis on interaction between the students and the tutor were implemented to provide immediate feedback. At the end of the term, the students from the experimental group were asked anonymously to complete a questionnaire in order to assess the course. Two clinical case scenarios were used for the evaluation of the students' performance in obtaining the most reasonable tentative diagnosis and differential diagnosis for these scenarios by the experimental group and the control groups. In the first case the average score obtained by the experimental group was higher than that of the control groups, and in the second case the average score obtained by the control group of the sixth year students were slightly higher than those of the fourth year students in the experimental and control group. However, the approach of the sixth year students to tentative case diagnosis was inadequate. The discriminative power when evaluating the ability to make a reasonable tentative diagnosis and a differential diagnosis was higher with the first case, but the difference did not reach statistical significance. The results of the questionnaire reflected the feasibility of the course. The students in the experimental group showed high agreement that this course promoted their interest not only in learning but also encouraged discussion. Furthermore, they identified an effect on their learning, their ability to selflearning, their attitude to active learning, and the identification of deficits in self-learning. In addition, they perceived that there was a behavioral effect when learning clinical diagnosis parallel to this elective course. These students also perceived the tutors as being enthusiastic, knowledgeable, analytical and accessible. They were also highly appreciated for their stimulating teaching, and their encouragement of the student's devotion to work. The short-term results of this experimental course identified its feasibility and that it had promise. Further study of the short term and long term effect of such a symptom-based pathophysiology course on diagnostic skill is needed to prove that it has a role in the reform of the clinical diagnosis curriculum at the intermediate level of a clinical diagnosis course.