實習醫學生的整合性學習評量研究:直接觀察式評量的必要性

透過直接觀察和提供回饋，老師將不僅有助於醫學生提升臨床技能，也可以監督醫學生提供最佳的臨床照護。「直接觀察」的評量方式主要包括：客觀結構式臨床考試（objective structured clinical examination, OSCE）及迷你臨床演練評量（mini-clinical evaluation exercise, mini-CEX）。輔仁大學醫學系的整合性臨床醫學學習評量共包括五大類，實習護照成績、平時成績、筆試成績、OSCE 成績及mini-CEX 成績。本研究分析2008 學年51 位六年級實習醫學生五大類學年成績的彼此相關性，尤其是同屬直接觀察性質的OSCE 或mini-CEX 成績與其他四項成績的相關性。全部OSCE 成績與全部護照成績 （r=0.30、p=0.0352）、全部平時成績 （r=0.29、p=0.0408）、與全部筆試成績 （r=0.40、p=0.0034）有顯著正相關，不過全部的相關係數r 值卻都只在0.28 至0.40 之間，相關性有限；就個別科別分析時，僅急診科OSCE 成績與mini-CEX 成績屬於中強度相關 （r=0.68、p<0.0001）。將全部五科彙總的mini-CEX 成績與其他四項成績則都沒有統計相關性。比較輔醫學生兩家主要實習醫院，在各科細項成績的差異，發現平時成績與mini-CEX 成績，在兩院間有顯著差異，代表此兩項成績較容易受到老師主觀評分的影響。另外以醫師執照考試通過為否，分組比較學生在校成績，只有筆試成績有顯著差異。總結，OSCE 與mini-CEX 此兩種屬直接觀察性質的 「循例示範」（Shows how） 及「實際執行」（Does） 層級評量，可以彌補單純以筆試評量實習醫學生的缺陷。OSCE 的相對鑑別度高，兼具形成性和總結性評量價值。mini-CEX 因為老師評分偏仁慈，在搭配立即回饋下，其教學價值遠高於評量意義。如能透過平日連續臨床案例的mini-CEX 經驗累積，再搭配制式OSCE 考試，將能使醫學生獲得更好的臨床技能。

By directly observing learners with patients and providing feedback, faculties help students to improve clinical skills and help patients through better supervision of clinical care. "Direct observation" assessments include: objective structured clinical examination (OSCE) and the Mini Clinical Evaluation Exercise (mini-CEX). The Department of Medicine, Fu Jen Catholic University developed an integrated assessment system consisted of a total of five categories: learning passports, clinical performance rating, written test, OSCE and mini-CEX. We analyzed the correlation among all these five categories of assessment in their year results for 51 sixth-year students in the school year of 2008. We paid special attention on the correlation between the scores of assessment with the nature of direct observation (OSCE and mini-CEX) and that of the rests of assessment tools. Summated OSCE scores positively correlated with summated passport scores (r=0.30、p = 0.0352), clinical performance ratings (r=0.29、p = 0.0408), and written test scores (r=0.40、p = 0.0034), but all of the correlation coefficient (r value) were around 0.28 to 0.40 with modest correlation. Analyzing individual specialty showed OSCE scores had a good correlation (r= 0.68、p<0.0001) with mini-CEX scores in the emergency medicine. Summated mini-CEX scores had no correlation with the other four categories of scores. Comparison of the scores between two major teaching hospitals found significant differences in the categories of clinical performance rating and mini-CEX scores, indicating these two categories of scores being more susceptible to subjective ratings from faculty. In addition, regarding the pass or fail in the Medical Licensing Examination, the failed students had a significantly poor written test scores during their clerkship. In summary, both mini-CEX and OSCE, sharing the same nature of 「direct observation」 assessment, can compensate the pitfall resulted from simple domain assessment form a sole written assessment. Due to the relatively high discrimination power, OSCE may play the roles of both formative and summative assessment. The leniency of mini-CEX rating in conjunction with timely feedback could provide a better role of teaching instead of assessment. Its value is far higher than the assessment of teaching significance. Through the consecutive mini-CEX practice for accumulated experience, and the formal test with OSCE, the medical students could achieve better clinical skills.