應用迷你臨床演練評量于實習醫學生的評量結果

Implementation of the Mini-CEX during the Clerkship Part of Medical Training

10.6145/jme.200806_12(2).0003

葉建宏(Jiann-Horng Yeh)；邱浩彰(Hou-Chang Chiu)；周定遠(Ting-Ywan Chou)

迷你臨床演練評量 ； 立即回饋 ； 實習醫學生 ； 月暈效應 ； mini Clinical Evaluation Exercise ； immediate feedback ； clerkship ； halo effect

Journal of Medical Education

12卷2期（2008 / 06 / 01）

77 - 83

繁體中文

大部分文獻中「迷你臨床演練評量(mini-CEX)」皆是以住院醫師為評量對象。文獻中針對實習醫學生的研究則相當有限。本系於2006年11月開始於五及六年級實習醫學生試辦一年4次的mini-CEX評量，截至2008年1月底共回收68份評量表。評量時的直接觀察時間，平均19.1分鐘、評量後立即回饋平均15.6分鐘。在非病房評量比在病房評量時直接觀察的時間稍長，回饋時間也顯著較長。大外科系評量的直接觀察及立即回饋時間皆比在大內科系顯著較長。在mini-CEX「整體適任」項目的平均評分為5.9分。書面回饋中「優良回餽」中11%出現「疑月暈效應」，「不良回餽」32%有「疑月暈效應」。總結，經此次台灣地區第一個報導實習醫學生使用mini-CEX評量的經驗，證實使用mini-CEX來評量實習醫學生是實際可行的，而且除了傳統的內科學系適合使用mini-CEX評量外，連外科學系也適合。相對於國外mini-CEX用於住院醫師評量的經驗，本研究針對實習醫學生執行mini-CEX評量，發現評分也較高的現象，所需的立即回饋時間較長。至於部份的評量出現「月暈效應」及不良的書面回饋，則需經由持續的師資培育課程，以改善整體評量的品質。

Currently, the mini Clinical Evaluation Exercise (mini-CEX) is a well-developed tool that is used to evaluate clinical skills. Most reported studies have described its application for the rating of residents. There have been limited reports on the use of the mini-CEX as part of the clerkship curriculum. We had implemented four mini-CEX ratings per year in our 2-year clerkship since November 2006 at the College of Medicine, Fu-Jen Catholic University. Up to January 2008, we had collected 68 rating sheets including 39 ratings related to the medical specialty and 29 related to the surgical specialty. Seventy nine percent of the mini-CEX ratings had happened on the ward. The mean duration of direction observation was 19.1 minutes and the mean duration of immediate feedback was 15.6 minutes. Interestingly, the mean durations of direct observation and feedback were significantly longer in a non-ward setting, either the outpatient clinic or the emergency department. The encounters in the surgical specialty spent more time on both direct observation (p=0.0357) and feedback (p=0.0288) compared to the assessments in the medical specialty. The mean score for overall competency over the 68 ratings was 5.9. Across all seven domains, no significant differences could be found. The score in the physical examination domain was the lowest and that in the medical interview domain was the highest. There was no statistically significant difference between the scores for the medical and surgical specialties. Forty-six written feedbacks (68%) were classified as good feedback. Twelve (18%) were found to suffer from a suspected halo effect. This effect was closely associated with a poor written feedback based on the fact that there was a higher proportion of suspected halo effect among those ratings with poor written feedback (7/22, 32%) comparing to those with good feedback (5/46, 11%) (p=0.0404). In summary, the implementation of the mini-CEX as part of clerkship was feasible and practical based on this first study using mini-CEX rating as part of the clerkship curriculum in Taiwan. In addition to the traditional medical specialties, the surgical specialty was also suitable for mini-CEX evaluation. Comparing our experience of the mini-CEX rating here with that during residency, we found that there were higher scores and longer feedback times during clerkship mini-CEX rating. Regarding the ratings themselves, the presence of the halo effect and poor written feedback implies that a continuous faculty training program is warranted in order to improve the quality of the mini-CEX ratings.

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