醫學生臨床倫理經驗之分析：結構式「關鍵事件報告」之應用

Analysis of Medical Students' Ethical Experience in Their Clerkship: The Application of Structured Critical Incident Report

李錦虹(Gin-Hong Lee)；王志嘉(Chih-Chia Wang)；鄒國英(Kuo-Inn Tsou)；邱浩彰(Hou-Chang Chiu)；林明德(Ming-Teh Lin)

倫理困境 ； 臨床實習 ； 關鍵事件報告 ； 醫學生 ； clinical clerkship ； critical incident report ； ethical dilemma ； medical student

教育心理學報

44卷4期（2013 / 06 / 01）

812 - 828

繁體中文

醫學生在實習過程中的倫理經驗，常常成為教師探討與教學的主要內容。過去，醫學教育者常常讓學生以自由書寫的作業方式整理其實習經驗，沒有問固定的格式要求。本研究首度嘗試以「關鍵事件報告」的形式，深入分析學生面對臨床倫理問題時的各種認知與心理反應。研究參與者：臺灣北部某大學醫學系六年級修習必修科目「醫學倫理」學生26位，其中男生17位，女生9位。工具：Griffin（2003）所設計的「關鍵事件報告」，其中包含「事件」、「情緒」、「原因」、「分類」、「一般意涵」、「專業標準」、「個人立場」、「行動」八個結構式欄位。研究過程：修習醫學倫理課程的某醫學院六年級學生，依教師要求，用「關鍵事件報告」的格式書寫五年級實習期間一件印象深刻的倫理事件， 徵求同意後納為本研究之分析對象。資料分析: 專家先為每個事件列出相關的倫理原則，再比較研究者與學生在倫理原則歸類土的一致性，並進行有關情緒、信念及行動等作業內容的質性分析。結果：（1）醫學生與專家在倫理原則歸類上的一致性並不高，（2）倫理事件及衝突大多與「不傷害」、「尊重自主」倫理原則有關；（3）學生對倫理事件的信念為以病人為本位、醫師應其備專業素養、醫師應重視病人身心的全人照護；（4）學生常見的情緒包括：對病患的困惑為難與同情不捨之感受；對醫師的生氣、不認同、及失望感受；（5）學生面對倫理問題的行動意向主要是「溝通」。結論：醫學生的臨床倫理經驗包含內容豐富的認知、個人信念、情緒及行動意向。結構式的「關鍵事件報告」有助於學生完整的呈現這些經驗，增進教師對於學生臨床倫理經驗的理解，提升臨床倫理教師的教學品質。

Background: In the past, teachers used to ask medical students to reflect on their clinical experience through free-form writing. In this study, a structured form called ”Critical Incident Report” was implemented. Through systematic and multi-dimensional writing, better understanding of students' psychological and cognitive reactions toward clinical ethical problems could be expected.Methods: Twenty-six medical school students who were taking the compulsory course ”Medical Ethics” participated in the current study. Seventeen of them were males and 9 of them were females. Participants were asked to each complete a Critical Incident Report (CIR) (Griffin, 2003) on an ethically sensitive event they had found unforgettable during their practicum in their 5th year of medical school. The CIR contained eight columns: what, emotions, why, classification, general meaning, professional standards, position, and actions. The data obtained from the CIR written by these 26 students with consent was subjected to a qualitative analysis. Both the experts' and the students' classification of the events on their CIRs were compared to ethical principles listed by medical ethics experts according to each student's event report.Results: 1. There was a significant difference between the medical students and the experts in the ethical principles they categorized the events into. 2. The most remarkable ethically sensitive events and conflicts experienced by the students were most frequently related to ”non-maleficence” and ”autonomy”. 3. Beliefs that students held toward ethical\y sensitive events included patient-centered practice, professionalism, and holistic health care. 4. Students' emotions about the events included confusion and sympathy toward patients, and negative feelings such as anger, disapproval or disappointment toward clinical physicians. 5. When faced with ethical dilemmas, students usual\y adopted ”communication” as the primary strategy.Conclusion: Medical students' experience with medical ethics in the clinical setting involved a broad range of issues including cognition, personal beliefs, emotions, and intentional actions. The CIR helped students record and present these experiences, which could also serve as a reference for future improvement of medical ethics education and research.

1. Akabayashi, A.,Slingsby, B. T.,Kai, I.,Nishimura, T.,Yamagishi, A.(2004).The development of a brief and objective method for evaluating moral sensitivity and reasoning in medical students.BMC Medical Ethics,5(1),E1-E7.
2. Brady, D. W.,Corbie-Smith, G.,Branch Jr, W. T.(2002)."What's important to you?" : The use of narratives to promote self-reflection and to understand the experiences of medical residents.Annals of Internal Medicine,137(3),220-223.
3. Branch Jr, W. T.,Pels, R. J.,Hafler, J.(1998).Medical students' empathic understanding of their patients.Academic Medicine,73(4),360-362.
4. Branch Jr, W. T.,Pels, R. J.,Lawrence, R. S.,Arky, R.(1993).Becoming a doctor-Critical incident reports from third-year medical students.New England Journal of Medicine,329(15),1130-1132.
5. Christakis, D. A.,Feudtner, C.(1993).Ethics in a short white coat-the ethical dilemmas that medical students confront.Academic Medicine,68(4),249-254.
6. Eckles, R. E.,Meslin, E. M.,Gaffney, M.,Helft, P. R.(2005).Medical ethics education: Where are we? Where should we be going? A review.Academic Medicine,80(12),1143-1152.
7. Egan, E.(2002).Ethics training in graduate medical education.The American Journal of Bioethics,2(4),26-28.
8. Fard, N. N.,Asghari, F.,Mirzazadeh, A.(2010).Ethical issues confronted by medical students during clinical rotations.Medical Education,44(7),723-730.
9. Flanagan, J. C.(1954).The critical incident technique.Psychological Bulletin,51,327-358.
10. Griffin, M. L.(2003).Using critical incidents to promote and assess reflective thinking in preservice teachers.Reflective Practice,4(2),207-220.
11. Griffin, M.,Scherr, T.(2010).Using critical incident reporting to promote objectivity and self-knowledge in pre-service school psychologists.School Psychology International,31(1),3-20.
12. Hebert, P. C.,Meslin, E. M.,Dunn, E. V.(1992).Measuring the ethical sensitivity of medical students: A study at the University of Toronto.Journal of Medical Ethics,18(3),142-152.
13. Hicks, L. K.,Lin, Y.,Robertson, D. W.,Robinson, D. L.,Woodrow, S. I.(2001).Understanding the clinical dilemmas that shape medical students' ethical development: Questionnaire survey and focus group study.British Medical Journal,322(7288),709-710.
14. Huijer, M.,van Leeuwen, E.,Boenink, A.,Kimsma, G.(2000).Medical students' cases as an empirical basis for teaching clinical ethics.Academic Medicine,75(8),834-839.
15. Kasman, D. L.(2004).Doctor, are you listening? A writing and reflection workshop.Family Medicine,36,549-551.
16. Kelly, E.,Nisker, J.(2009).Increasing bioethics education in preclinical medical curricula: What ethical dilemmas do clinical clerks experience?.Academic Medicine,84(4),498-504.
17. Kemppainen, J. K.(2000).The critical incident technique and nursing care quality.Journal of Advanced Nursing,32(5),1264-1271.
18. Lincoln, Y. S.,Guba, E. G.(1985).Naturalistic Inquiry.Beverly Hills, CA:Sage.
19. Mofidi, M.,Strauss, R.,Pitner, L. L.,Sandler, E.(2003).Dental students' reflections on their community-based experiences: The use of critical incidents.Journal of Dental Education,67(5),515-523.
20. Nogueira-Martins, M. C. F.,Nogueira-Martins, L. A.,Turato, E. R.(2006).Medical students' perceptions of their learning about the doctor-patient relationship: A qualitative study.Medical Education,40,322-328.
21. Parker, D.,Webb, J.,D''Souza, B.(1995).The value of critical incident analysis as an educational tool and its relationship to experiential learning.Nurse Education Today,15(2),111-116.
22. Tsai, F. C.(2000).The four principles approach to bioethics.Journal of Medical Education,4,12-26.
23. Wilson, H. J.,Ayers, K.(2004).Using significant event analysis in dental and medical education.Journal of Dental Education,68(4),446-453.
24. 王志嘉(2009)。論醫療上「病人自我決定權」及其刑法相關問題。東吳法研論集，5，53-94。
25. 蔡甫昌(2000)。生命倫理四原則方法。醫學教育，4，12-26。

1. (2020)。醫學院校醫事法律課程之現況與展望──以作者15年之教學實踐經驗為核心。醫事法學，26(1、2)，1-25。