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

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上的一致性，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、醫師應具備專業素養、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 ethically 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 usually 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.