醫學生對實證醫學應用之探討

The Application of Evidence-Based Medicine for Medical Students

羅羚蓁(Lin-Chen Loh)

指導教授 ： 蔡崇弘

中山醫學大學/醫學院/醫學研究所/碩士(2011年)

https://doi.org/10.6834/CSMU.2011.00033

摘要

實證醫學（Evidence-Based Medicine, EBM）乃指謹慎的、明確的、明智的使用現有最好的證據於醫療照護個別病人上。美國醫學院協會（Association of American Medical Colleges）建議實證醫學的原則需要納入整個醫學教育的課程；國內外學者亦皆表示，各醫學院應將實證醫學在醫學生實習之前列為獨立的必修課程。至今，探討教育效益的研究仍不斷地持續中，但大多數是就單項效果進行探討，鮮少文獻再更深入地瞭解認知、態度與各方面相關因素交互影響的情形。因此，本研究除了探討教育訓練，並利用結構方程模式分析（structural equation modeling, SEM），呈現醫學生認知、態度對個人應用、預期應用之間的關係和相關地影響因素。
本研究以台中某醫學中心參加EBM基礎教育訓練課程之醫學系五、六年級醫學生為調查對象。以量表為評量工具，具有4個構面共含26題問項，分別為實證醫學認知、個人應用狀況、未來應用及態度，各構面信度值分別為0.926、0.847、0.913及0.892。未來應用為6分制，其他構面為5分制。總共發出量表50份，回收50份，回收率為100%。結果以描述性分析和推論性分析呈現，分析方法以SPSS for windows 12.0版套裝軟體進行信效度分析、Spearman 相關分析及簡單線型迴歸分析（simple regression analysis）和Amos 7.0版軟體進行結構方程模式分析。
整體調查結果，學生對認知的敘述皆為正面的表態，平均分數為4.77 ± 0.45。個人應用上，醫學證據的蒐尋頻率以每隔一天或兩天和每個禮拜的佔最最高（皆30％），資料庫的運用頻率以網際網路＞教科書＞次級資料庫（20％＞16％＞12％），原始文獻與Cochrane Liabrary 則表態不佳。而對未來應用之敘述亦為正向的表態，平均分數為4.67 ± 1.09。另外，態度方面以負向題評核之結果，平均分數為2.32 ± 0.95，了解學生經教育之後則具正面的表現。構面之間，認知與未來應用具相關（r=0.36；p＜0.05），個人應用與未來應用亦具有相關（r=0.33；p＜0.05），經線型迴歸分析，認知上之變異的14.7 ％可被未來應用上之變異所解釋（F = 8.105；p＜0.01）。以及未來應用之變異的15.9 ％可被個人應用所解釋（F = 8.868；p＜0.01）。最後，結構方程模式分析之結果，表示學生對實證醫學抱持良好的認知與態度，則將影響學生在未來應用的表現（p＜0.05）。
本研究為首度利用結構方程模式分析，確立實證醫學教育效益評估之模型。由模型了解，課程訓練的確有助於醫學生對實證醫學的認知與態度之表現，並達到促進醫學生將來進一步學習及運用實證醫學的動機。而在未來，可做為精進實證醫學教育課程之參考。

關鍵字

實證醫學 ； 結構方程模式分析 ； 醫學教育

並列摘要

Evidence-based medicine（EBM）is defined as discretional and well-defined protocol based on best available data that can be applied to clinical care. Association of American Medical Colleges has suggested that EBM must be included in the entire medical educational curriculum. As a matter of fact, EBM has brought a huge impact in clinical practices and medical education. It is a consensus shared among international scholars that EBM should be accommodated in pre-internship curriculum for medical students. However, the educational benefits of EBM is still under debate. Most studies only address this issue unilaterally, without considering the potential interplay among practitioners' or students' perception and attitude toward EBM.
In this study we conducted a questionnaire-based investigation on a group of 5th- and 6th-year medical students enrolled at a medical institution in Taichung that practices EBM training. Our design of questionnaire was based on the evaluation tool developed by Johnston et al. The evaluation table consists of 4 categories including basic understanding of EBM, personal utilization of EBM, general attitude and awareness of EBM's future prospects, and each category contains 26 questions. The confidence level of each category is 0.926, 0.847, 0.892, and 0.913, respectively. This evaluation helps us to assess the potential influence of EBM training on medical students by analyzing their performance in these 4 categories and in any given interrelated categories.
We sent out 50 evaluation papers in total and received 50 in return, so the questionnaire retrieval rate is 100%. Here we utilized descriptive analysis and inferential method to present the data. The analysis was performed on SPSS for Windows 12.0 package for confidence profiling, Spearman correlation analysis and simple regression analysis, and on Amos 7.0 for structural equation modeling.
The overall data indicates the students are positive about EBM; the average score is 4.77 ± 0.45. In the category of personal perception of EBM applicability, the average score is 2.90 ± 1.22. The searching frequency of EBM is the highest for every other day and every two days（about 30% each）.
The frequency of database utilization is the highest for the Internet and then followed by textbooks and secondary database（20％＞16％＞12％）, while original literature and Cochrane Library are much less utilized. The overall attitude toward EBM's future applicability and prospects is positive as well, with an average score of 4.67 ± 1.09. On the other hand, the average score for questions that negate EBM is only 2.32 ± 0.95, supporting that the students are mostly favorable for EBM. In addition, the comparison among different categories shows that basic understanding of EBM is correlated with the awareness of EBM's future prospects/applicability（r=0.36；p＜0.05). Similarly, personal utilization of EBM is positively correlated with EBM's future prospects/applicability（r=0.33；p＜0.05）. The result of linear regression analysis points out the variance from the basic understanding of EBM (14.7 ％) can be well interpreted by the variance of the awareness of EBM's future prospects/applicability（F = 8.105；p＜ 0.01）. Likewise, the variance from EBM's future prospects/ applicability (15.9 ％) is consistent with personal utilization of EBM（F = 8.868；p＜0.01）. Finally, the result obtained from structural equation modeling suggests that students who demonstrate well understanding and good attitude toward EBM have correlated performance on EBM's future prospects/applicability（p＜0.05）. Although we are unable to specify what types of influences of a good understanding and attitude toward EBM may have on students' database utilization, personal utilization of EBM seems to exert an influence on EBM's future prospects/applicability.
This is the first time that a study of EBM ever performed by structural equation modeling to obtain a model for evaluating EBM's educational benefits. Based on the obtained model, we are able to better understand whether and to what extent EBM training influences medical students in terms of their motivation and desire to employ EBM in their future practices. As for the evaluation of how EBM training has impacted on real application, we should try to understand and trace the history of how academic resources/libraries are used by the students in order to have a better idea of EBM training's efficacy. In the future, we should also include the factors of patients and behavioral changes in the evaluation to better assess the connection between medical students' clinical performance and EBM, and thereby improve EBM curriculum accordingly.

並列關鍵字

Evidence-Based Medicine ； Structural Equation Model (SEM） ； Medical Education

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