能力導向之醫學教育發展

The Development of Competency-Based Medical Education

能力導向的醫學教育（competency-based medical education, CBME）早在1970年代被提出來，是指培養專業人員在符合當地社會規範下，從事醫療行為，滿足當地的醫療需求。醫學教育是根據社會所認定的勝任能力（簡稱能力）與核心能力（core competency）設計課程或學程來訓練，以學員為中心的教學與評估，讓受訓者達成可信賴的專業活動。為了讓CBME能夠從核心能力架構，落實到平時的臨床教學訓練評估中，許多醫學教育的學者及機構提出落實CBME的具體做法，最具影響力的做法就是可信賴專業活動（entrustable professional activities，EPAs）及里程碑計畫（milestones project）。前者是由荷蘭學者Olle ten Cate 所提出美國（Association of American Medical Colleges, AAMC）已訂出完整專業活動的內容，後者則是由美國（Accreditation Council for Graduate Medical Education, ACGME）所主持規劃。在美國從2012開始實施里程碑計劃。2012年衛福部開始計畫成立「住院醫師計畫認定委員會」（Residency Review Committee, RRC），以統籌台灣23個部定專科醫師的訓練。首要之務即是改善及進階所有學科訓練準則，以美國ACGME六大核心能力為主幹，強調教學品質與成效。在國內台灣急診醫學會推展CBME確認了23項次能力共231個里程碑。以麻醉專科醫學會為例，除傳統6大核心能力外，另制定了25項次核心能力與285項里程碑作為學習與評量之指標。長庚醫院神經外科也加入住院醫師訓練的行列。RRC也將在2018年實施里程碑計畫。

This article presents an overview of the history of medical education in Western countries. The development of curriculum design started from system-based curriculum to problem-based learning then to clinical presentation. Because of the public health demand and social accountability in health care and the concept of medical education is shifty to competency-based movement in 21^(st) century. The physician competency frame work has been developed in many different countries these include United States, Canada, Scotland and Netherlands. The definition of competency is an observable ability interpreting knowledge, skills and attitudes. Entrustable professional activities (EPAs) were designed to link competencies in clinical practice and milestone is a behavioral descriptor that marks a level of performance in clinical practices. The ministry of Health and Welfare Taiwan started the Program of Residency Review Committee (RRC) in 2012, will implement the milestone projects in resident training program in 2018.