培養醫學生具備倫理基礎之醫病溝通能力的新課程

A Novel Course for Fostering Ethics-Based Communication Competency among Medical Students

台灣近年來醫療糾紛與訴訟快速成長，嚴重影響醫師執業行為與生態，因此促進醫病關係和諧乃當前醫學人文教育的重要方向。本計畫的目的是針對訓練醫學生在醫療體系行醫（systmes-based practice, SBP）下，培養具備倫理基礎之醫病滿通能力所設計的一種創新課程，並以克伯屈模式探討學生的「反應」、「學習」與「行為」等三個層次的成效。本課程由六年級醫學生實習兩週，以6或7位學生為一組，輪流到醫院內各位單位學習護理、藥事、放射、檢驗、批價掛號（批掛）、病歷、保險、會計、醫院管理（醫管，包含醫院組織架構、人事規章、採購保管實務、醫療品質、病人安全、績交評核、行政決策實務）、社工/醫療糾紛（醫糾）、倫理法律與整合等12種模組課程。

There are more increasing events of medical dispute in Taiwan during recent years, 80% of which are criminal events, and the compensation breaks the previous records. They deeply influence the behavior of physician's practice and environment. Therefore, how to increase peaceful relationship of physician and patient is the imperative topic in the current medical education. The aims of this study were to design a novel course of ethics-based communication skills, and evaluate the outcomes in terms of reaction, learning and behavior with the Kirkpatrick's model. The 2-week systems-based practice (SBP) course included rotation among twelve blocks made up of nursing, pharmacy, radiology, laboratory-related work, registration, medical records, insurance, accounting, administration, social work/medical dispute, medical ethics and law, and integration block. The learning content in each block included "the most important issue for each unit that most physicians do not know" along with the routine operation of various units. The contents used diverse methods including lectures, case workshops, case discussions and common questions/answers. The participants were 6th grade medical students, who formed groups of six or seven students. They took turns to participate in each SBP course. A "Block Feedback Sheet" was introduced to assess the reactions of the medical students (Level 1of Kirkpatrick's model). The assessment of the students' learning (Level 2) consisted of pre-test scores, post-test scores, the students' performance scores given by their block teachers and the student's participation in discussions during the reflection/feedback block. Furthermore, a preliminary assessment of behavior change (Level 3) was made based on submitted reports regarding students' commitment to behavior change and their desire to apply the content of the SBP course later in practice. A total of 94 students took the SBP courses given by China Medical University Beigang Hospital during the 2012 academic year. Students' feedback on various block courses gave a satisfaction rating of 4.5±0.6 (Likert scale: 5 strongly agree; 1 strongly disagree) overall. When the learning outcome was assessed, the objective pre-test and post-test scores of SBP were 71.3±8.8 and 86.9±10.8, respectively, based on 40 multiple choice questions (one out of four answers is correct), which is with significant improvement (p<0.001, 95% confidence interval 13.2-18.2); the objective pre-test and post-test scores of medical ethics and law were 56.2±16.1 and 83.1±14.4, respectively, based on 10 multiple choice questions (one out of four answers is correct), which is with significant improvement (p<0.001, 95% confidence interval 23.1-30.7). Furthermore, the mean subjective score from the twelve blocks teachers was 86.8±2.6 and the mean participation score for the reflection/feedback block was 90.2±2.0. Finally, the mean preliminary assessment for commitment to behavior change at a later point was 89.1±1.6. The course does indeed successfully provide medical students with initial experiences in ethics-based communication skills under systems-based practice based on assessment at three levels, namely reaction, learning and behavior.