培養醫學生具備倫理基礎之醫病溝通能力的新課程

A Novel Course for Fostering Ethics-Based Communication Competency among Medical Students

鄭希彥(Shi-Yann Cheng) ； 高忠漢(Chung-Han Kao) ； 蔡承諺(Cheng-Yeng Tsai) ； 陳偉德(Walter Chen)

《台灣醫學》 18卷3期 (2014/05) Pp. 270-278

https://doi.org/10.6320/FJM.2014.18(3).02

摘要

台灣近年來醫療糾紛與訴訟快速成長，嚴重影響醫師執業行為與生態，因此促進醫病關係和諧乃當前醫學人文教育的重要方向。本計畫的目的是針對訓練醫學生在醫療體系行醫（systems-based practice, SBP）下，培養其備倫理基礎之醫病溝通能力所設計的一種創新課程，並以克伯屈模式探討學生的「反應」、「學習」與「行為」等三個層次的成效。本課程由六年級醫學生實習兩週，以6或7位學生為一組，輪流到醫院內各單位學習護理、藥事、放射、檢驗、批價掛號（批掛）、病歷、保險、會計、醫院管理（醫管，包含醫院組織架構、人事規章、採購保管實務、醫療品質、病人安全、績效評核、行政決策實務）、社工／醫療糾紛（醫糾）、倫理法律與整合等12種模組課程。課程內容以「各單位最希望醫師知道，但醫師往往不知道」為主；教學方式採多元方式進行。以「模組課程回饋表」來評估學生的「反應」；以前、後測的成績、各模組教師對學習表現之評分與導師對反饋座談的評分，來評量「學習」成效；並根據心得報告，是否認同課程內涵尤其是倫理原則與法律規範，而願意應用於爾後的行醫與醫病溝通上，來初步探討「行為」的改變。接受本課程的醫學生共94名，對課程的整體滿意度為4.5 ± 0.6（5為非常滿意，1為很不滿意）。醫療體系的題測驗題之前測為71.3 ± 8.8，後測為86.9 ± 10.8，進步分數其統計之顯著差異（p ＜ 0.001，95%信賴區間13.2-18.2）；而倫理法律10題測驗題之前測為56.2 ± 16.1，後測為83.1 ± 14.4，進步分數亦具統計之顯著差異（p ＜ 0.001，95%信賴區間23.1-30.7）。由模組教師評量之學習表現為86.8 ± 2.6；由導師評量之綜合表現為90.2 ± 2.0。對於課程後行為改變的心得報告評量為89.1 ± 1.6。本課程可增進醫學生在醫療體系下之行醫能力，並奠定以倫理素養為基礎的醫病溝通基本技能，故可作為醫學生的入門訓練模式。

關鍵字

稱職能力 ； 醫療體系下行醫能力 ； 醫學倫理 ； 醫學法律 ； 整合式課程 ； 問題導向式學習 ； 知情同意

並列摘要

There are more increasing events of medical dispute in Taiwan during recent years, 80% of which are criminal events, and the compensation breaks the previous records. They deeply influence the behavior of physician’s practice and environment. Therefore, how to increase peaceful relationship of physician and patient is the imperative topic in the current medical education. The aims of this study were to design a novel course of ethics-based communication skills, and evaluate the outcomes in terms of reaction, learning and behavior with the Kirkpatrick’s model. The 2-week systems-based practice (SBP) course included rotation among twelve blocks made up of nursing, pharmacy, radiology, laboratory-related work, registration, medical records, insurance, accounting, administration, social work/medical dispute, medical ethics and law, and integration block. The learning content in each block included ＂the most important issue for each unit that most physicians do not know＂ along with the routine operation of various units. The contents used diverse methods including lectures, case workshops, case discussions and common questions/answers. The participants were 6th grade medical students, who formed groups of six or seven students. They took turns to participate in each SBP course. A ＂Block Feedback Sheet＂ was introduced to assess the reactions of the medical students (Level 1of Kirkpatrick’s model). The assessment of the students’ learning (Level 2) consisted of pre-test scores, post-test scores, the students’ performance scores given by their block teachers and the student’s participation in discussions during the reflection/feedback block. Furthermore, a preliminary assessment of behavior change (Level 3) was made based on submitted reports regarding students’ commitment to behavior change and their desire to apply the content of the SBP course later in practice. A total of 94 students took the SBP courses given by China Medical University Beigang Hospital during the 2012 academic year. Students’ feedback on various block courses gave a satisfaction rating of 4.5 ± 0.6 (Likert scale: 5 strongly agree; 1 strongly disagree) overall. When the learning outcome was assessed, the objective pre-test and post-test scores of SBP were 71.3 ± 8.8 and 86.9 ± 10.8, respectively, based on 40 multiple choice questions (one out of four answers is correct), which is with significant improvement (p ＜ 0.001, 95% confidence interval 13.2-18.2); the objective pre-test and post-test scores of medical ethics and law were 56.2 ± 16.1 and 83.1 ± 14.4, respectively, based on 10 multiple choice questions (one out of four answers is correct), which is with significant improvement (p ＜ 0.001, 95% confidence interval 23.1-30.7). Furthermore, the mean subjective score from the twelve blocks teachers was 86.8 ± 2.6 and the mean participation score for the reflection/feedback block was 90.2 ± 2.0. Finally, the mean preliminary assessment for commitment to behavior change at a later point was 89.1 ± 1.6. The course does indeed successfully provide medical students with initial experiences in ethics-based communication skills under systems-based practice based on assessment at three levels, namely reaction, learning and behavior.

並列關鍵字

general competency ； systems-based practice ； medical ethics ； medical law ； integrated course ； problem-based learning ； informed consent

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