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Mini-CEX 迷你臨床演練評量. 林俞仲醫師. 2010-04-06. Training requests. Form Time Structure Content regularity. Contrell D. et al., Medical Education 36: 1042 – 1049, 2002. 現代醫師應具備的條件. 生物醫學知識 (Biomedical sciences) 行為與社會科學 (Behavioral & social science) 人道主義 (Humanities) 與醫學倫理 (Ethics) - PowerPoint PPT Presentation
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Mini-CEX迷你臨床演練評量
林俞仲醫師林俞仲醫師
2010-04-06
Training requests
FormForm
TimeTime
StructureStructure
ContentContent
regularityregularity
Contrell D. et al., Medical Education 36: 1042 – 1049, 2002
世界醫學教育聯盟
生物醫學知識 (Biomedical sciences)
行為與社會科學 (Behavioral & social science)
人道主義 (Humanities) 與醫學倫理 (Ethics)
醫療專業風範 (Medical professionalism)
一般的臨床技能 (General clinical skills)
臨床決策能力 (Clinical decision making skills)
現代醫師應具備的條件
Relationship between Knowledge and Performance
Does
Shows how
Knows how
Knows
Pro
fess
iona
l aut
hent
icity
Performance
Behavior
Knowledge
Miller GE. The assessment of clinical skills/competence/performance.
Academic Medicine (Supplement) 1990; 65: S63-S7
臨床能力:評估Patient Care
Medical Knowledge
Practice-Based Learning
and Improvement
Interpersonal and
Communication Skills
Professionalism
Systems-Based Practice
What You Do
What You Know
How You Get Better
How You Interact with
Others
How You Act
How you Work Within the System
臨床評量
選擇題選擇題 問答題或口試問答題或口試 模型或模擬病人訓練裝置模型或模擬病人訓練裝置 學習護照或病歷審核學習護照或病歷審核
知識知識知其所以然知其所以然表演表演實作實作
臨床能力
不容易客觀評估 從教育訓練角度來看,應該運用客觀、適當評估方法,來了解各類臨床教學計畫成效
國內缺乏一個良好的評估指標 傳統紙筆測驗是否能測得真正臨床能力 ?
學生實際臨床能力表現為何?
臨床能力為導向的教學臨床能力為導向的教學Competence-based LearningCompetence-based Learning
Attitudes 態 度Skills 技 巧Knowledge 知 識
對 學 生 的 評 估 Student portfolioStudent portfolio Medical record auditsMedical record audits 360º evaluation360º evaluation Preceptor ratingPreceptor rating Mini-CEX, DOPSMini-CEX, DOPS OSCEOSCE Case presentationCase presentation Oral examination, MCQOral examination, MCQ Patient management questionPatient management question Essay questionEssay question Multiple-choice questionMultiple-choice question
Does
Showhow
Knows how
Knows
Miller GE, Acad Med 1990
評 估
透明化透明化對於評估者以及學習者都很重要 對於評估者以及學習者都很重要 學習者需要知道會以哪些條件來評估他們的表現
評估者需要知道如何使用評估工具以及評斷學習者表現所使用的條件
沒有任何單一評估工具可以同時整體評量所有
核心能力
Mini-CEX
醫療面談技巧 Medical Interviewing Medical Interviewing
SkillsSkills
理學檢查 Physical Examination Physical Examination
SkillsSkills
人道品質專業 Humanistic Humanistic
ProfessionalismProfessionalism
臨床判斷 Clinical JudgmentClinical Judgment
諮商衛教 Counseling SkillsCounseling Skills
組織效能組織效能 Organization/ EfficiencyOrganization/ Efficiency
整體臨床能力 Overall Clinical Overall Clinical
CompetenceCompetence
Mini-CEX
ABIM (American Board of Internal Medicine) ABIM (American Board of Internal Medicine)
發展推薦的評量工具發展推薦的評量工具 可行性很高可行性很高 , , 教師學員皆認同教師學員皆認同
(Norcini JJ, et al. Ann Med 1995)(Norcini JJ, et al. Ann Med 1995)
於於 2121 所醫院進行前導研究所醫院進行前導研究 , , 頗獲好評 頗獲好評 (Norcini JJ, et al. Ann Med 2003)(Norcini JJ, et al. Ann Med 2003)
信效度優於傳統評量方法 信效度優於傳統評量方法 (Duming SJ, et al. Acad Med 2002)(Duming SJ, et al. Acad Med 2002)
可適用於醫學生可適用於醫學生(Hauer KE. Acad Med 2000 & Kogan JR. Acad Med 2002)(Hauer KE. Acad Med 2000 & Kogan JR. Acad Med 2002)
Mini-CEX 的特色
Direct observational evaluation Patient care, clinical setting Immediate feedback learning
Min
i CE
X
執行方
式
時間
人員
事情
物件
地點
每月一次,每次 20 分鐘
一位臨床老師一位學員一位病患
觀察學員臨床技能
病房、門診、急診、 ICU
評量紀錄單
評量表單評量表單 : :
教師: 主治醫師 研究醫師 總醫師 教師: 主治醫師 研究醫師 總醫師 住院醫師 住院醫師
學員: 學員: M5 M6 M7 R1 R2 R3 M5 M6 M7 R1 R2 R3 其他其他時間: 年 月 日 上午 時間: 年 月 日 上午
下午 晚上下午 晚上地點: 門診 急診 一般病房 加地點: 門診 急診 一般病房 加
護病房護病房病人: 男 女 年齡: 新病人: 男 女 年齡: 新
病人 舊病人病人 舊病人診斷:診斷:病情複雜程度: 低 中 高病情複雜程度: 低 中 高
診療重點: 病情蒐集 診斷 治療 診療重點: 病情蒐集 診斷 治療
諮商衛教諮商衛教
直接觀察住院醫師 ( 醫學生 ) 執行重點式的診療工作,可在任何時間及任何地點實施
1
評量表單評量表單 : :
1. 1. 醫療面談 醫療面談 2. 2. 身體檢查 身體檢查 3. 3. 人道專業 人道專業 4. 4. 臨床判斷臨床判斷5. 5. 諮商衛教 諮商衛教 6. 6. 組織效能組織效能7. 7. 整體評量整體評量劣 劣 1 2 3 4 5 6 7 8 1 2 3 4 5 6 7 8
99 優優 未符要求 達到要求 未符要求 達到要求
優秀 優秀 ( ( 未觀察未觀察 ))
臨床教師依七種項目評量學員之稱職能力
2
醫療面談: 鼓勵病人說病史;有效的利用問題或導引來獲得所需之正確而足夠的訊息;對病人之情緒及肢體語言能適當的回應。
Medical interviewing skills facilitates patient’s telling of story; effectively use
questions/ directions to obtain accurate, adequate information needed; responds appropriately to affect, non-verbal cues
評 項量
醫療面談技巧
稱呼病人稱呼病人自我介紹自我介紹對病人說明面談之目的對病人說明面談之目的表現尊重表現尊重同理心同理心 (( 感同身受感同身受 ))
能鼓勵病人說病史能鼓勵病人說病史適切發問及引導以獲得正確且足夠的訊息適切發問及引導以獲得正確且足夠的訊息 對病人情緒及肢體語言能有適當的回應對病人情緒及肢體語言能有適當的回應
Medical Interviewing Skill
Medical Interviewing Skills
Starts with open-ended questionsStarts with open-ended questions Progresses with specific questionsProgresses with specific questions Does not ask multiple questionsDoes not ask multiple questions Does not ask presumptive/leading questionsDoes not ask presumptive/leading questions Does not interrupt patientDoes not interrupt patient Asks for clarification if necessaryAsks for clarification if necessary Logic sequencing of questionsLogic sequencing of questions Segment summarySegment summary
Lane JL & Gottlieb RP. Structured Clinical Observations. Pediatrics 2000
身體檢查: 依效率及合理之次序,依病情均衡地操作篩選或診斷之步驟;告知檢查事項;適當而審慎地處理病人之不適。
Physical Examination Skills
Follow efficient, logical sequence; balances screening/ diagnostic steps for problem; informs patient; sensitive to patient’s comfort, modesty
評 項量
Physical Examination Skills
Washes handsWashes hands Minimizes discomfortMinimizes discomfort Preserves modestyPreserves modesty Explains to parent what doingExplains to parent what doing Explains to child what doingExplains to child what doing Sequence matches cooperation levelSequence matches cooperation level Build rapportBuild rapport Correct techniqueCorrect technique
Lane JL & Gottlieb RP. Structured Clinical Observations. Pediatrics 2000
人道專業: 表現尊重、憐憫、感同身受;建立信賴感;處理病人對舒適、受尊重、守密、渴望訊息的需求。
Humanistic Qualities/ Humanistic Qualities/ ProfessionalismProfessionalism
Shows respect, compassion, empathy, establishes trust; attends to patient’s needs of comfort, modesty, confidentiality, information
評 項量
Humanistic Qualities/Professionalism
My Dr. seems to take a personal interest in me Even my problem is small, my Dr. is concerned I have confidence in my Dr.’s decisions My Dr. respects my beliefs I would talk to my Dr. if something troubling me My Dr. takes an interest in my home life My Dr. is easy to talk to My Dr. seems to know what I am going through when I tell
him/her about a problem
Hauck FR, et al. Humanism in Physicians. Family Med 1990
臨床判斷: 適當的處置診斷步驟;考慮利弊得失。Clinical Judgment Selectively orders/ performs
appropriate diagnostic studies, consider risks, benefits.
評 項量
Clinical Judgment
Formulating a D.D. using history and physical Formulating a D.D. using history and physical
examinationexamination
Developing a prioritized problem list to select testsDeveloping a prioritized problem list to select tests
Applying principles of sensitivity, specificity, and Applying principles of sensitivity, specificity, and
pretest predictive value probabilitiespretest predictive value probabilities
Assessing risks, benefits, and costs of treatment optionsAssessing risks, benefits, and costs of treatment options
Involving patient in decision makingInvolving patient in decision making
Goroll AH, et al. Reforming core clerkship. Ann intern Med 2001
諮商衛教: 解釋檢查或處置的基本理由;獲得病
人 ,,同意;有關處置之教育與諮商Counseling Skills Explains rationale for test/
treatment, obtains patient’s consent educates/ counsels regarding management
評 項量
Counseling Skills
The patent’s role in decision makingThe patent’s role in decision making
AlternativesAlternatives
Pros (benefits) and cons (risks) of the alternativesPros (benefits) and cons (risks) of the alternatives
Uncertainties associated with the decisionUncertainties associated with the decision
As assessment of the patient’s understanding of the As assessment of the patient’s understanding of the
decisiondecision
An exploration of the patient’s preferencesAn exploration of the patient’s preferences
Braddock CH, et al. Informed decision making. JAMA 1999
組織效能: 按優先順序處置;及時而適時;歷練而簡潔。
Organization/ Efficiency Prioritize; is timely; succinct.
評 項量
Organization/Efficiency
Clinical practice guidelines: systemically developed statements to assist practitioner and patient decision about appropriate healthcare for specific clinical condition
The practice guideline is a management plan that enables healthcare providers to make sequential decisions about testing or therapy in a given clinical situation
Gerszten PC. Neurosurg Focus. 1988
整體適任: 判斷、整合、愛心、效率、功能的 整體評量。 Overall Clinical Competence Demonstrates judgment,
synthesis, caring, effectiveness, efficiency.
評 項量
Overall Clinical Competence
Opening/closing the interviewOpening/closing the interview Introduce self; calls patient by name; shakes hands entering; Introduce self; calls patient by name; shakes hands entering;
shakes hands leaving shakes hands leaving Relationship skillsRelationship skills
Listens carefully (nods, “mm-hm”); Reflects and legitimizes Listens carefully (nods, “mm-hm”); Reflects and legitimizes patient’s feelings or concerns; offers partnership, support, or patient’s feelings or concerns; offers partnership, support, or praisepraise
Personal mannerPersonal manner Appearance; good eye contact; appropriate body language, Appearance; good eye contact; appropriate body language,
facial expression, and tone of voice; use silence facial expression, and tone of voice; use silence appropriatelyappropriately
Lane JL & Gottlieb RP. Structured Clinical Observations. Pediatrics 2000
直接觀察時間:直接觀察時間: 20 20 分鐘,回饋時間:分鐘,回饋時間: 15 15 分鐘分鐘
教師對本次評量滿意程度:教師對本次評量滿意程度:低 低 1 2 3 4 5 6 7 8 91 2 3 4 5 6 7 8 9 高 高 學員對本次評量滿意程度:學員對本次評量滿意程度:低 低 1 2 3 4 5 6 7 8 91 2 3 4 5 6 7 8 9 高高
教師評語: 教師評語: 多次打斷病患陳述多次打斷病患陳述,,未解釋檢查之必要性未解釋檢查之必要性及可能風險。未確定病人了解病情;未告知提名其他及可能風險。未確定病人了解病情;未告知提名其他治療選擇。治療選擇。
教師簽章:教師簽章: 學員簽章: 學員簽章:
評量表單 :評量表單 : 提供學員教育性回饋
3
什麼是臨床教學的回饋 ?
可矯正學習的錯誤 可確認學習符合標準 可幫助了解教學的效果 花費少許的代價,可使學習大力進步 是師生雙向互動的
好 的 回 饋 Descriptive Descriptive rather than evaluativerather than evaluative
Specific Specific rather than generalrather than general
Behavior or actionBehavior or action rather than the trait or rather than the trait or
charactercharacter
SoonSoon after the encounter after the encounter
Positive-Negative-Positive sandwichPositive-Negative-Positive sandwich
Amin & Eng. Basic in Medical Education. 2003 Amin & Eng. Basic in Medical Education. 2003
執行 Mini-CEX 的準備
教師要有一致性評分標準教師要有一致性評分標準 舉辦共識研討會舉辦共識研討會 基本分數基本分數 教師要有足夠的臨床能力教師要有足夠的臨床能力 建立自己的範本建立自己的範本 不同疾病不同疾病 不同地點不同地點
Mini-CEX: 一般評分標準
醫學生醫學生 實習醫學生實習醫學生 住院醫師住院醫師 研究醫師研究醫師 新任之主治醫師新任之主治醫師 資深主治醫師資深主治醫師
4 4 分分5 5 分分6 6 分分7 7 分分8 8 分分9 9 分分
陳偉德等人,醫學教育 10: 232 – 239, 2006
Mini-CEX: 評分結果
Mini-CEX Faculty N = 57 Resident N = 50
Medical interview 6.2 ± 1.3 6.9 ± 1.3
Physical examination 5.9 ± 1.4 6.7 ± 1.3
counseling 5.6 ± 1.4 6.6 ± 1.4
Clinical judgment 6.0 ± 1.3 6.8 ± 1.4
Humanism / professionalism 6.0 ± 1.4 7.0 ±1.5
陳偉德等人,醫學教育 10: 232 – 239, 2006
To be continued
Mini-CEX: 評分結果
Mini-CEX Faculty N = 57 Resident N = 50
Organization / efficiency 5.7 ± 1.4 6.8 ± 1.4
Overall competence 6.2 ± 1.4 7.0 ± 1.2
Observation time (min) 16.1 ± 7.2 16.6 8.5
Feedback time (min) 9.8 ± 4.3 12.5 7.0
陳偉德等人,醫學教育 10: 232 – 239, 2006
Mini-CEX
實施時段:實施時段: 上午 上午 29 (59.2%)29 (59.2%) 下午 下午 20 (40.8%)20 (40.8%)
實施地點:實施地點: 門診 門診 3 (6.1%)3 (6.1%) 一般病房 一般病房 46(93.9%)46(93.9%)
病患性別:病患性別: 男性 男性 30 (61.2%)30 (61.2%) 女性 女性 19 (38.8%)19 (38.8%)
病情複雜程度:病情複雜程度: 低低 3 (6.1%)3 (6.1%) 中中 39 (79.6%)39 (79.6%) 高高 7 (14.3%)7 (14.3%)
診療重點:診療重點: 病情蒐集病情蒐集 75.5%75.5% 診斷診斷 59.2%59.2% 治療治療 14.3%14.3% 諮詢衛教諮詢衛教 26.5%26.5%
統計時間: 97.9~97.10 N=49
Mini-CEX
NN 未觀察未觀察 RangeRange MinMin MaxMax Mean SDMean SD
醫療面談醫療面談 4949 00 22 33 55 4.20 0.504.20 0.50
身體檢查身體檢查 2727 2222 22 33 55 3.67 0.553.67 0.55
人道專業人道專業 4747 22 33 33 66 4.28 0.654.28 0.65
臨床判斷臨床判斷 4949 00 33 33 66 3.92 0.573.92 0.57
諮商衛教諮商衛教 4444 55 33 33 66 3.95 0.753.95 0.75
組織效能組織效能 4949 00 33 33 66 4.10 0.514.10 0.51
整體適任整體適任 4949 00 22 33 55 4.12 0.484.12 0.48
NN MissingMissing RangeRange MinMin MaxMax Mean SDMean SD
直接觀察時間直接觀察時間 4747 22 3030 1010 4040 21.28 8.4421.28 8.44
回饋時間回饋時間 4747 22 4545 55 5050 18.17 9.6718.17 9.67
統計時間: 97.9~97.10 N=49
Mini-CEX
N 未觀察 Range Min Max Mean±SD
醫療面談 124 0 2 3 5 4.21 ± 0.53
身體檢查 43 81 2 3 5 3.74 ± 0.58
精神狀態檢查
(12/8新增 )
45 0 2 3 5 4.22 ± 0.67
人道專業 112 12 3 3 6 4.25 ± 0.59
臨床判斷 123 1 3 3 6 4.07 ± 0.56
諮商衛教 107 17 3 3 6 4.05 ± 0.69
組織效能 124 0 3 3 6 4.1 ± 0.58
整體適任 124 0 2 3 5 4.23 ± 0.57
統計時間: 97/09-98/01 月, N=124 人
Mini-CEX
N Missing Range Min Max Mean±SD
直接觀察時間 122 2 30 10 40 21.34 ± 6.29
回饋時間 121 3 45 5 50 18.6 ± 7.72
N Missing Range Min Max Mean±SD
教師對本次評量滿意度 119 5 5 3 8 5.53 ± 1.67
學員本次評量滿意度 117 7 7 2 9 6.1 ± 1.83
參考資料
台中榮民總醫院吳明儒醫師、陳德源醫師 台中澄清醫院許惟邦醫師 中國醫藥大學陳偉德醫師 高雄長庚紀念醫院李建德 凱旋醫院曾憲洋醫師