Chung-Sheng Lai 賴春生 , M.D., E.M.B.A., Ph.D 台灣高雄醫學大學醫學院院長 台灣整形外科醫學會理事長

1. Undergraduate clinical skill education-Experience in Kaohsiung Medical University畢業前臨床技能教育-高雄醫學大學之經驗 Chung-Sheng Lai 賴春生, M.D., E.M.B.A., Ph.D 台灣高雄醫學大學醫學院院長 台灣整形外科醫學會理事長

2. Overview of the content • Infrastructures for clinical skill education • Organ system-based clinical skill teaching &GOSCE • Department-based clinical skill teaching&assessment • Standardized patient training emphasized on effective feedback • Current OSCE in Taiwan • The next step of OSCE : • Interprofessional GOSCE • Summary

3. Medical Education Committee-教育委員會 臨床技能學習中心（校級） Clinical skill center (university level) College of medicine（醫學院） Affiliated hospital（附設醫院） Clinical Medical education committee （臨床醫學教育委員會） Curriculum committee (college level) （課程委員會，院級） Department of clinical education & training （臨床教育訓練部） School of medicine （醫學系） Clinical skill center (Hospital level) (臨床技能中心，院級 ) Curriculum committee (school level) （課程委員會，系級） Clinical skill and OSCE committee (臨床技能及OSCE委員會 ) Organ system-based clinical skills & assessment (M3-4,BM1-2) Department-based clinical skills & assessment (M5-7,BM3-5) Infrastructures for Clinical Skill Instruction (課程為主的臨床技能與評估) (科為主的臨床技能與評估)

4. 2002 OSCE in KMU 2005 OSCE in KMU

5. Importance in 3 elements of data collection for diagnosis • 70% by history taking • 20% by physical examination • 10% by laboratory & other tests Medicine is a science of uncertainty and an art of probability. 一種疾病有許多面貌 Sir William Osler

6. New Curriculum 〈since 2005〉 臨床技能從一年級開始培育：人際關係 臨床技能 New Curriculum

7. Integrating clinical skills to the curriculum • Clinical skills can precisely perform only by repeated practices besides the didactic lectures. • 15 blocks based on organ systems were integrated in the new curriculum (2005). • Organizer of each block is the most important key-person for implementation of the organ system-based skills instruction & assessment. • Chief of each clinical department is the main person responsible for implementation of the department-based skills instruction and assessment. • 104 clinical competencies minimally required for medical graduates suggested by Taiwan Joint Commission on Hospital Accreditation(台灣醫策會 )were all included.

8. 台灣醫學生畢業時必須具備之基本臨床技能 • 理學檢查的技巧 (Examination Skills)：共37項 • 影像學的解讀 ( Visual Image Interpretation ) ：共6項 • 實驗診斷的技巧 ( Laboratory Skills ) ：共8項 • 程序上的技巧 ( Procedural Skills ) ：共29項 • 治療的技術 ( Therapeutic Skills ) ：共22項 • 其他：溝通技巧、倫理決策、醫療品質、實證醫學的相關能力....

9. 基礎臨床課程整合小組 課程組/ 15教學單元 PBL執行委員會 Clinical skill / OSCE 教材審查小組 召集人/副召集人 1-2教案/block 6-10小時/block 課前審查 4-6 weeks/block 18-22 hours/weeks 6小時/教案 GOSCE/年 課後評估 基礎臨床教師 修正教材 PBL 負責教師 Clinical skill 負責教師 基礎臨床課程整合

10. 教案編寫 專家審查 （三位） OSCE執行 委員會審查 OSCE 實地測驗 教案修改 根據考官與學生 回饋意見修改教案 OSCE及Clinical skill 執行委員會 • OSCE特色 • 依整合型課程設計，將醫策會所定之醫學生畢業前臨床技能，共6大類104小項，分類編入課程中實作演練。 • 教案書寫格式統一化 • 建立各clinical skill 的標準操作流程SOP • 學生 • 醫三、醫四：Organ-based clinical skills • 醫五、醫六：Department-based clinical skills • 醫七：Integrated real patient-based clinical skills

11. New Curriculum Clinical skill授課時數

12. 將clinical skill列入課程中

13. 4th week（15.5hrs） 上課地點：Lecture在勵學大樓A2教室，PBL在6W PBL教室 Assessment andfeedback at the end of each block

14. Organ system (Block) - based clinical skills training and GOSCE • Establishing the SOP of basic skills related to each block • Practicing various skills by using medical models, simulators, standardized patients, animals, computer assisted teaching devices…etc. • Group OSCE was held at the end of the year (M 3-4, BM 1-2)

15. 抽血與靜脈注射 Block 3 (Hematology and neoplasia)-based clinical skills training 2005.11.08 M3.BM1 clinical skill

16. Block 4 (Cardiovascular system)-based clinical skills training 中心靜脈導管 心電圖

17. Station 1 Station 2 Station 3 Station 4 Station 5 Station 6 2006 M3.BM1 GOSCE

18. 學生GOSCE六站滿意度（6.19施測）Student’s Satisfaction about OSCE 全班201人；有效問卷153份（回收率：76％）

19. Department –based clinical skills training and assessment • Instructing the clinical skills related to each clinical department〈core competencies〉 • Practicing various clinical skills through real patients, standardized patients, patient’s scenarios, Lab data, images, multimedia…etc. • Clinical skill assessment was held at the end of rotation of each clinical department .

20. 臨床技能執行－實習醫學生 • 參與主治醫師病房迴診 • 參與主治醫師門診 • 主治醫師床邊教學 • 臨床病例討論會 • 臨床文獻研讀 • 制訂核心課程 核心技能 整型外科 Department-based clinical skills test

21. Lecture – Practice – Immediate feedback Basic surgical skills training

22. X光判讀 心電圖判讀 血液抹片判讀 尿液觀察及鑑別診斷 實務測驗 心音聽診 Department-based clincal skill examination • Internal Medicine • 28 stations • 5 minutes per station

23. Evaluation form for clinical competence

24. Real Patient-based clinical skill teachingVS-R-Intern-clerk integrated instruction History taking Physical examination Surgical planning Immediate feedback Team work approach Informed consent Opening – Discussion – Synthesis

25. Assessment of clinical skills • OSCE ( Objective Structured Clinical Examination ) • DOPS( Direct Observation of Procedural Skills ) • Mini-CEX (Mini-clinical Evaluation Exercise) • CBT( Computer Based Test ) • Check with checklist. • Videotape recording. • Feedback by physicians, experts, real patients,and SP.

26. OSCE的優點 • 測驗內容標準化且可以控制 • 正確性高 • 再現性高 • 可以客觀的評估臨床技能、知識、態度 • 模擬病人可以提供學生及教師回饋 • 可以彌補筆試的不足

27. OSCE用於教學與評估的領域 • 病史的詢問 • 溝通技巧、諮商技巧及病人教育 • 身體檢查 • 臨床技術(量血壓、抽血、眼底檢查等) • 檢驗結果判讀及解說 • 臨床推理，解決問題 • 醫學倫理問題 • 緊急情況的反應及處置 • 醫師及病人的安全

28. 標準病人的來源與訓練 • 招募： • 透過校園徵募，徵求自願者加入，包括職員工及社區人士，願意接受訓練成為標準病人，提供學生實作OSCE。 • 訓練： • 至少接受三次『當病人』的訓練。 • 第一次面談： 討論劇本的內容並要求在下次會面之前理解記住案例的內容。 • 第二次面談：　　　 針對案例進行問答，然後依照劇本演練數次，回饋意見，並校正標準病人的表演。 • 第三次面談： 精熟表演、通過考核，成為OSCE標準病人。 • 費用： • S.P.完成訓練給予1000元訓練費，之後每次演練給予1000元。 • 標準病人中心： • 儲備合格之標準病人。 • 彼此聯誼、交換

29. Concerns and challenges of standardized patients (SPs) • SPs are skilled at simulating historical and physical findings, but many find it difficult to give effective feedback. • Effective feedback is the key part of teaching and learning process, it helps learners learn better, and faster. • SPs can be taught to give effective feedback by using Quality of SP Feedback Form (QSF) to train. • SPs are like mirrors.

30. Principles for giving feedback • 7-step approach • Encourage self-reflection.(鼓勵反省) • Describe specific behaviors.(敘述特殊行為 ) • Use the sandwich technique.(鼓勵 - 批評 - 鼓勵) • Limit negative feedback.(限制負面回饋) • Demonstrate empathy.(表達同情) • Encourage learner questions.(鼓勵發問) • Verify feedback and thank learner.(感謝) 2004 Win May, Dixie Fisher USC keck school of Medicine

31. Purpose of Using the quality of SP Feedback Form (QSF) • A training tool for SPs, SPs rate each other, and learn each other. • Improving the verbal feedback besides the written feedback. • Better inter-rater reliability is gained after training, and SPs appear to better understand how to give feedback.

32. OSCE台灣發展現況 • 2009.10.09：台灣醫學院校長會議 • OSCE及格訂為醫學生畢業之必要條件，並建議考選部修訂第二階段醫生執照考試之報考資格。 • 2009-2010：OSCE資格認證中心的訪視評鑑。 • 2010.07.24：成立台灣標準化病人協會 • 2010.08.11： • 彙集各校教案，建立題庫，並確立OSCE及格標準辦法 ( Borderline Group Method ) • 擬定考官及SP/SP Trainer 認證作業要點，並訂定申訴委員會設置要點。 • 2010.09.26：2011台灣OSCE聯考共識會議 • 各校推薦2~4位負責台灣OSCE聯考之代表。 • 2011：台灣醫學院畢業生OSCE聯考。 • 2012：考選部正式執行高階 OSCE之考試。

33. Uniprofessional OSCE Interprofessional GOSCE Multiprofessional GOSCE What is the Next Step of OSCE?

34. Why Interprofessional Education (IPE) for Clinical Skills ? • Health care professionals do not function in isolation • People work together in small interdisciplinary group for many aspects of day-to-day patient care • However learners are typically trained in separate disciplines and educational programmes, only coming together as a team at the end point of clinical care • For patient safety and holistic care, IPE offers benefits to team working outcome

35. Summary ( I ) • Better integration between the activities of the clinical skill center and thecurriculumis essential 〈not just to show off to the visitors 〉 to promote the learning effectiveness of the students. • Full supporting system through a well-designed infrastructures is of paramount importance to embbed numerous transferable skills to students both in breadth & in depth. • The range of practice, assessment, and feedback of OSCE should be well-planned according to the institution’s resources and learner’s need.

36. Summary ( II ) • Effective feedback is an important component of teaching & learning process, quality of feedback training system for SPs and tutors is essential. • Roadmap of clinical skill learning starts from general education, organ system-based curriculum, department-based core competencies, to real patient-based clinical practice should be established & integrated. • The trend of OSCE may move from uniprofessional OSCE to interprofessional or multiprofessional GOSCE based on the team work for holistic care in the real world.

37. Find the right way to set the sail of clinical skill education before the wind! Thank you for your attention! Find the right way to set the sail of clinical skill education before the wind! 博學之、審問之、慎思之、明辨之、篤行之！