以病人為焦點之整合性臨床技能訓練

能力導向是目前臨床醫學教育的主流方針，與此同時，由於物料及電子科技的進步，促使醫學模擬(medical simulation)逐漸成為醫學教育一個重要的領域，過去僅以「做中學」的臨床醫學學習方式已較不被接受，學生在到臨床之前必須接受醫學模擬訓練。然而，在醫學教育日趨以能力導向及醫學模擬逐漸推廣的同時，必須考量各種臨床能力通常不會單獨運用，而是經常面臨需要多種技能相互配合來處理的各種狀況。如果在訓練期間只給予某種臨床技能的單獨訓練，學得的技能未來在臨床上需要使用時便可能不易施展。因此，發展一項能整合多項臨床技術訓練的課程有其必要性。我們引用英國皇家理工學院Kneebone教授的整合式臨床技能訓練課程，設計一項「以病人為焦點」之整合性臨床技能訓練，試用於醫學系五年級的臨床醫學訓練課程中。教案設計之原則為教導一種常用之臨床技術配合常見之醫病溝通場景。在本課程中，我們共設計了「替急性尿潴留病人導尿」、「替肺炎惡化氣喘加劇的患者氣管插管」、「替突發心跳停止的病人作心肺復甦術及向家屬解釋病情」以及「替貧血的住院病人輸血」四個教案。在經由多次演練的觀察及學生的回饋可以確認此課程的可行性及效益。未來我們將致力於此項訓練的推廣和精緻化，相信在不斷努力耕耘之後會有更豐碩的成果，使醫學生的實習歷程更踏實、更順利以及更具效能，最後能達成醫療服務的最終目標－促進病人安全及提升對病人的照護品質。

關鍵字

能力導向醫學教育；以病人為焦點；整合性臨床技術訓練；標準化病人

並列摘要

Competence-oriented education is currently the mainstream of clinical medical education. At the same time, the concept of ”learning by doing” has become less acceptable because medical simulation, using low or high fidelity facilities in the pre-clinical settings, is now considered to be an essential part of clinical training. However, most of those skill-training programs usually focus on one particular skill and this is not compatible with the real healthcare environment. Using the format of the Integrated Procedural Performance Instrument (IPPI), as reported by Kneebone R, et al., we developed an experimental course of medical simulation that integrated communication skills, the patient-doctor relationship, physical examination and/or basic clinical procedures for medical students attending National Yang-Ming University. Four cases were designed and tested; these were ”to perform a urinary catheterization of an anger patient who is suffering from acute urinary retention”, ”to intubate a conscious patient with pneumonia and acute respiratory failure”, ”to resuscitate a patient with sudden cardiac arrest and breaking the bad news of the patient's death to his family”, and ”to prepare a blood transfusion for a patient who has been admitted for evaluation of chronic anemia”. Our preliminary results were promising and revealed that the integrated clinical scenarios used for clinical skills training that were introduced by Dr. Kneebone (Imperial College, London) are also feasible in Taiwan. Although this is new territory in terms of clinical education, it is also full of challenges. This approach is certainly worthy of further development because we believe this training model is a great help to medical students and residents because it develops and promotes their own clinical skills and competencies.

並列關鍵字

competence-oriented medical education ； patient-focused ； integrated clinical skill training ； standardized patient

參考文獻

Chen YL,Wu CL,Yang HW(2006).Implementation and development of a clinical-skills workshop for interns and clerks: our five-year experience.J Med Educ.10,154-161.

Liu M,Huang YS,Liu KM(2004).Minimal required clinical competencies of medical graduates-a study of competency oriented medical education.J Med Educ.8,168-188.

Block EF,Lottenberg L,Flint L(2002).Use of a human patient simulator for the advanced trauma life support course.Am Surg.68,648-651.