以客觀結構式臨床考試來評量七年級醫學生的醫病溝通技能

Assessment of Communication Skills in a Group of Seventh-Year Medical Students with the Objective Structured Clinical Examination (OSCE)

醫病溝通技巧是醫學生所需接受培養的基本核心能力之一。醫病溝通是現代醫學教育之中，醫師養成的必修課程。本文針對輔仁大學醫學系七年級醫學生進行客觀結構式臨床考試（OSCE）時醫病溝通站測驗結果作分析；由44 位醫學生進行全部12 考站的臨床技能測驗，其中7 站為與標準化病人（standardized patient）互動的情境站 （簡稱SP 站）、5 站以模具及操作技巧為主的技巧站。12 考站包括：換藥、高脂血症服藥諮商 （醫病溝通站）、頭痛、縫合、急性呼吸困難、急性腹痛、心肺復甦術、急性陰道出血、發燒及喉嚨痛、痙攣、一氧化碳中毒及心電圖判讀，由考官及標準化病人共同評量成績。在醫病溝通站的成績與大部分的SP 站的考官或SP 評分相關性較弱，但與全部技巧站的得分則無線性相關。在醫病溝通站的考題得分分析中，發現絕大多數（95.5％）學生皆能通過該站測驗，學生在一般禮儀及態度都能適切表現，在「聆聽技巧」及「協商技巧」表現也令人滿意，其餘「解釋」、「容許」及「建議」部分則仍有進步的空間。至於比較醫病溝通站兩位考官間的信度差異時，發現兩位考官評分一致性與學生得分有一樣的趨勢，除了「聆聽技巧」及「協商技巧」相當高外，其餘「解釋」、「容許」及「建議」部分則考官一致度不到50％。因此，七年級醫學生在醫病溝通技巧方面，雖然都已具備良好的禮儀、態度、及部分技巧，但是在專業知識的專精與口語通俗化的訓練仍有待進一步的加強。另外溝通技巧此種人文為主的評量，需要考前妥適的考官共識營，以拉近考官間的評分差異。

Doctor-patient communication skills are pivotal to the medical practice and essential as one of the core abilities to be acquired by the students in their medical education. A group of 44 seventh-year students was assessed for the learning of the doctor–patient communication skills with an objective structured clinical examination (OSCE) which was divided into a basis of 12 evaluation stations: 7 stations designed with scenarios for interactions with standardized patients (SP) consisting in counseling for a patient with hyperlipidemia, recurrent headache, acute dyspnea, acute abdomen pain, acute vaginal bleeding, fever, convulsion, and CO intoxication, and 5 stations to evaluate the diverse procedure skills consisting in the change of wound dressings, suture, cardiopulmonary resuscitation, and EKG reading. Two raters in each SP-based station, both the raters and SPs, scored the students’ performance. The scores obtained in the doctor-patient interaction correlated modestly with the scores given by the raters and SPs among most of the SP stations, but had no linear correlation with the overall scores in the procedure skills stations. The majority of students (95.5%) succeeded in the doctor-patient interactive station as it was remarkable that most of the students have appropriate manners and attitudes during the doctor-patient interactions and satisfactory performance in terms of 'listening skill' and 'negotiation skill'. However, further improvement was needed in the skills for the fields of “explanation”, “acknowledgement”, and “recommendation”. The analysis and comparison of the scoring concordance between the two raters in this doctor-patient interactive station showed similar trends of the performance of the students with good concordance scores in the fields of 'listening' and 'negotiation' skills while the concordance of the scores for the rest of the skill fields, “explanation”, acknowledge”, and “recommendation” were less than 50%. In summary, this study demonstrated that the seventh-year medical students might be satisfactory in their manners, attitude, and some communication skills in the doctor-patient interactions, the need for a more solid professional medical knowledge and the training for a more appropriate oral communicational ability still needed to be further strengthened. In addition, it was to emphasize that in order to enhance the reliability and diminish the deviation of the scorings between the two raters in the evaluation of such humanity-based assessments, a well-formed consensus prior to the evaluation of the students among all the raters should be mandatory.