以標準病人評估實習學生於神經內科之臨床能力

Evaluating the Clinical Competence of the Intern

10.6145/jme.200509_9(3).0003

張博彥(Bor-Yann Chang)；謝正源(Jane-Yane Shieh)；許耀東(Yaw-Don Hsu)；王如娥(Carol Ju-O Wang)；高森永(Senyeong Kao)；張聖原(Sun-Yran Chang)；何善台(Shung-Tai Ho)

臨床能力 ； 標準病人 ； clinical competence ； standardized patient

Journal of Medical Education

9卷3期（2005 / 09 / 01）

233 - 240

繁體中文

為瞭解國防醫學院七年級學生之臨床能力實際表現，本研究嘗試神經疾病標準病人測驗方式，在醫學生臨床能力做一客觀比較，並希望建立本土化之標準病人評估模式。在經過嚴謹及標準化訓練六種神經疾病之標準病人後，先以專家效度進行評估標準病人之表現後，再安排十位住院醫師進行再測信度評估，得其相關係數達0.82，顯示標準病人測試方法具有良好之信度及效度。其後於門診診間安排標準病人測驗站以實際的臨床情境讓受測者（醫學系七年級學生）與標準病人互動，錄影後由評估者探評估表評核受測者實際臨床能力表現，同時探討可能影響因素與標準病人臨床能力測驗成績之關係。結果顯示在本次臨床能力測驗總分為120分，而受測者平均成績為82.5分。顯示在整體受測學生之臨床能力仍有提升之空間。再進一步觀察醫科七年級醫學生在臨床能力四部份表現（病史詢問、身體檢查、醫病關係及醫療處置）之平約成績（四部份滿分均為30分），發現受測者在此四部份之成績表現，優劣依序為「醫病溝通」（24.0分）、「醫療處置」（20.5分）、「病史詢問」（20.0分）、「身體檢查」（18.0分）。探討影響學生臨床能力之因素，顯示在已實習過神經內科之學生較未實習過神經內科之學生在有較佳表現。由標準病人臨床測驗，了解醫學系七年級學生在身體檢查訓練需要加強。本研究顯示標準病人在醫學生能力評估，可協助臨床教師了解醫學生臨床能力優缺點。

Clinical competence is one of the essential qualities for a qualified physician. Of all the methods of evaluating clinical competence now in use, the ”standardized patient” is generally acknowledged to be a reliable and effective tool. This study used standardized patient testing to better understand the actual clinical competence in neurological assessment of seventh-year medical students at the National Defense Medical College, and to develop a means of standardized patient evaluation that is effective for Taiwan. After rigorously training standardized patients in the symptoms of six diseases, the performance of the standardized patients was evaluated for specialist validity. Ten resident physicians we re then used to evaluate test-retest reliability and the correlation coefficient between the two was found to be 0.82. This indicates that the standardized patient testing method has excellent reliability and validity. An examination room at a hospital clinic was used as a testing station, where the students and the standardized patients could interact under actual clinical conditions. The interaction was videotaped and the assessors evaluated the students actual clinical performance using an evaluation check form, while also investigating possible factors influencing performance. The results were an average score of 82.5 out of a total score of 120 points, indicating that there is room for improvement in the overall performance of the students tested. Further observation of the performance of the students in the four parts of the clinical examination (history taking, physical examination, doctor-patient communication, medical management), each worth 30 points, showed that the students' performance, from highest to lowest, was as follows: doctor-patient communication (24 points), medical management (20.5 points), history taking (20 points) and physical examination (18 points). Investigation of possible factors influencing performance showed that students who had had internship experience in the neurology department performed better than students who had had none. The results of the standardized patient test indicate that students need to improve their physical examination skills. From the students' test scores, it is clear that internship experience is helpful in developing clinical competence. This result also indicates that the use of standardized patients in evaluating medical students can assist clinical tutors in understanding students' clinical strengths and weaknesses.

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