OSCE背景分析.doc

文獻蔡淳娟， OSCE實務，台北醫學大縱市立萬芳醫院，2007:16-21林政勳，客觀結構式教學測驗評量於放射技術學之應用，中臺科技大學放射科學研究所，2011年一月陳柏齡，臨床能力評介紹，國立成功大學醫學院附設醫院，一般醫學訓練中心OSCE整個概況傳統的醫學測驗(如選擇題、口試等)只能評量考生的醫學知識、以及部分的臨床技術及解決問題能力，無法真正反應醫師的臨床技術能力(尤其是詢問病史、身體檢查等表現能力)1960年代神經科醫師Dr. Barrows開始使用標準化病人來教導醫師臨床技能，提升了往後臨床技能教育的境界，西元1975年英國北方丹地大學教授Harden博士等人，首創以客觀結構式臨床技能考試(Object Structured Clinical Examination, OSCE)，論文發表於Br J ed，他們使用標準化病人，以設計好的範例，具結構式目的，在模仿醫療現場的考場下，一站站地測驗學生的臨床技能，評分者則依據直接觀察給予考生分數。隨著標準化病人在醫學教育上的普遍運用，1985年，Ian Hart及Ronald Harden 因此在舉行Ottawa舉行了Assessing Clinical Competence 研討會，持續進行至今，成為一個很重要的世界性醫學教育年會。Dr. Reznick在SIU(Southern Illinois University)受Dr, Barrows指導，拿到醫學教育碩士，回到加拿大主導Medical Council of Canada(MCC), 1990年加拿大成為世界第一個將OSCE納入醫師執照考試的國家，1994年美國ECFMG(Educational Commission for Foreign Medical Graduates)決定使用這種臨床技術考試來檢定美國海外醫師資格，隔年，美國國家醫師執照考試委員會(NBME, National Board of Medical Examination)，決定在四至七年之間，納入OSCE測驗。日本於2003起規定醫學生在進入臨床實習前須通過這種臨床技術考試，美國則拖到2004年開始把OSCE納入USMLE(United States Medical Licensing Examination )Step 2 CS(Clinical Skill)的考試，如今OSCE已成為當今醫學教育上為法被取代的測驗工具，也已經在全世界各醫學院與教學醫院教育中，被普遍用來測驗醫師或醫學生臨床的技能。 西元1975年英國北方丹地大學教授Harden博士等人，首創以客觀結構式臨床技能測驗的方法，客觀評估醫學生對臨床技能的學習成效。OSCE包含三個主要部分，即模擬醫療情境、教師客觀評估、檢討及雙向回饋。(一) 模擬醫療情境：利用標準化病人，設計多應(站)臨床教案，每一臨床教案分別測驗醫學系學生某一項(或多項)臨床技能，例如：病史詢問、身體檢查、溝通技巧、衛生教育、醫病關係與技術操作型技術等。每一站臨床教案都精心詳細的規劃，設計出結構清楚的模擬醫療環境，且具有明確的測驗目的。(二) 教師客觀評估：評分教師根據標準化清單上的項目，客觀地評估每位醫學生在每一臨床教案的表現。(三) 檢討與雙向回饋：測驗完畢後，教師與學生面對面檢討測驗中的優點及缺失，教師並給予學生適當的指正與建議，最後雙向回饋。概念起源於1975年，由蘇格蘭東部的丹地大學(University of Dundee)Harden 及Gleeson所提出，先由專家編寫出結構式的臨床測驗題目，在向同學解說及示範之後，以受過相關訓練的演員扮演病患(稱為標準化病人standardized patients,簡稱SPs)OSCE優缺點缺點：OSCE是昂貴的 OSCE是假的 考生會洩題 測驗之信度、效度、可行性不易達到令人滿意的水準優點：OSCE考的是臨床操作 OSCE可以考各種不同程度的臨床問題各站內容及複雜度可以調整到符合各種教育和考試的需求所有的考生都接受相同的測驗，在相同情境下，面對相的標準化病人，並且考試的時間都一樣長，因此可以減少這種表現型測驗的誤差考生面對的是不同的站、由不同的考官評分，因此，不像口試一般，不總成績不是由單一考給予，而是各站的分數總和，可以減少單一考官個人主觀意識的影響。實施OSCE來客觀評估臨床技能與態度，並非完美無缺，當然有優缺點，根據蔡淳娟醫師分析，優缺點如下：優點：OSCE可以評估學生的臨床操作技能 OSCE可以評估不同程度的臨床問題 各臨床教案內容及複雜程度，可依各種教育和考試的需求而加以調整所有的學生都接受相同的測驗，在相同的情境下，面對相同的標準病人或場景，並且使用相同的測驗時間，因此可以減少表現型測驗的誤差學生面對不同的臨床教案，由不同考官評分，所以不像口試測驗一般，其總成績不是由單一考官給予，而是各站的考官評分總和，如此可以減少單一考官個人主觀意識的影響。缺點實施OSCE需要耗費較多資源(包括人力、金錢、時間及空間等)場景為假的，無論教案設計如何擬真，仍非真實狀況，尤其因應考試需要，臨床技術常被分割為較小的部分來測驗考生，因此不易反應完整之臨床技能OSCE之考題雖然可以變化，但是難免有重覆之使用情形，有遭洩題之虞。這類表現型測驗仍然有誤差來源，其測驗的信度、效度、可行性，並非達到令人滿意之水準優點：能夠廣泛測驗各種臨床技能時間、站數夠多時信度很高相對評估偏差小缺點：需要訓練標準病人需動員許多教員，複雜且花費大選擇性臨床技能測缺乏給予學生回饋臨床核心能力評估學生臨床的能力病史詢問身體檢查簡易技巧判讀檢驗結果處理病人狀況溝通態度及專業素養是一個有組織的結構、可融入不同考試的方法黃國禎，形成性評量舉總合性評量，臺南大學前言評量扮演回饋的功能，用來了解學生的學習成果及調整或擬訂教師的教學策略，以達到最佳的教學效果(歐滄和，民91概念分析測驗 小測量評量 大 範圍較廣，以測驗、面談、專案實作、檔案評量等方式以診斷學生的能力，除了評估學生能力之外，還包括協助學生解決問題評量目的瞭爾學生的潛能與學習成就，作為判斷學生努力的程度診斷學生的學習困難與障礙，作為補救教學及個別輔導的依據估量教師教學的效率，提供教師改進教材教法的參考瞭解學生學習進步的情形，觸發學生的學習性趣提供家長參考，作為瞭解學生在校學習的情形Bloom et al.1981對評量的看法評量是一種用以確定學生學習水準和教學有效性的證據的方法評量包括了比一般期末考試更多種類的證據評量是澄清教育的重要目的與教學目標的一種輔助手段，以及確定學生按這些理想的方式發展到何種程度的一種過程評量作為一種回饋-校正系統，在教學過程的每一步驟判斷該過程是否有效；如果無效，必須及時採取什麼變革，以確保過程的有效性評量是教育研究與實踐的一種工具，用於查明在達成某一教育目的時，不同的歷程是否同樣有效其他學者對評量的看法評量是運用科學方法和技術，蒐集有關學生學習行為及其成就的正確資料，再根據教學目標，就學生學習表現的情形，予以分析、研究和評斷的一系列工作評量係指教師蒐集、綜合、解釋有關學生的各種資料，以協助教師進行各種教與學的歷程黃裕勝，劉敏，黃俊雄，劉克明，高雄醫學大學實施客觀結構式臨床測驗之經驗，高雅醫誌2007；23:161-9摘要客觀結構式臨床測驗(OSCE)是一種能客觀且公平地評量醫學生臨床技能的評量工具，目前廣泛應用於世界各國的醫學教育。然而，台灣大部分的醫學院才剛開始採用OSCE來評量學生能力。高雄醫學大學在2003年建立了台灣第一個標準化病人計劃，並且將標準化病人應用於OSCE。此文章敘述本校實行OSCE的過程，從資料蒐集、參觀國外臨床技能中心、咨詢外國醫學教育專家、舉辦國際研討會、設立OSCE委員會、編寫個案及訓練標準化病人，到實際實施OSCE及調查學生意見。大部分學豆對於測驗感到滿意，並覺得這是很好的學習經驗。基於本次經驗，OSCE委員會決定採用OSCE做為評估醫學生臨床能力的方法之一。OSCE除了廣用於評量醫學生之外，亦被用於評量牙醫系 、護理系、藥學系等醫學相關科系的學生，因此，我們將醫學系實施OSCE的經驗推廣至本校其他科系。Medical students clinical competences are traditionally assessed based on written examinations, and direct observation of their performance, although these procedures have their own limits. Written examinations can be used to test students knowledge of clinical and procedural skills, but over-reliance on this method may lead students to focus on memorizing these skills instead of practicing them.Development of KMU OSCEProgram TMAC (Taiwan Medical Accreditation Council) expressed concern about over-reliance on written examinations to assess medical students. Written examinations generally place more emphasis on the students knowledge base and thereby fail to assess students attitude and clinical. Evaluation of the OSCEStudent perceptionA questionnaire was conducted at the end of each administration of the OSCE, and the students were asked to evaluate seven aspects of the examination：exam content, exam environment, exam atmosphere; the performance of the SPs ; feedback from the faculty;the improvement in their own clinical skills as they progressed through the exam;and their overall satisfication with the exam.Huang CC, Chan CY, Wu CL, Chen YL, Yang HW, Huang CC, Chen CH, Huang WJ, Lee FY, Lin SJ, Chen JW, Assessment of clinical competence of medical students using the objective structured clinical examination: first 2 years' experience in Taipei Veterans General Hospital, J Chin Med Assoc 2010;73:11AbstractBACKGROUND: Competence-oriented education is currently the mainstream method of teaching clinical medical education. The objective structured clinical examination (OSCE) is a widely employed and accepted tool to measure the clinical competence of medical students. We describe the first 2 years' experience of OSCE in Taipei Veterans General Hospital.METHODS: At Taipei Veterans General Hospital, every 7(th)-year medical student has taken the OSCE since 2006. There were 15 stations in the first 2 years' OSCEs. In years 1 and 2, 133 and 132 students were assessed by the OSCE, respectively. The content of the OSCE included internal medicine, surgery, pediatrics, obstetrics and gynecology, communication, and emergency training. All categories and results of examinees' evaluation at each station were recorded inclusively and compared statistically.RESULTS: The average scores of students from the 15 stations ranged from 47.7 ± 16.4 to 93.7 ± 8.5 in 2007. The score for communication skills was the lowest, whereas the score for Micro-Sim was the highest. Communication skills and electrocardiography interpretation were the 2 categories in which most of the students failed. A reliability analysis was conducted of the 2007 OSCE questions. The overall score and reliability (Cronbach's reliability) was 0.641. The difference between the impacts on reliability after deleting a test item ranged from 0.59 to 0.65 for all stations. This meant that every station had a similar impact on reliability after being deleted. The squared multiple correlation, R(2), of the reliability of each item was between 0.12 and 0.49, with chest X-ray interpretation being the lowest. The item-total correlation was between 0.10 and 0.41, with interactive case being the lowest.CONCLUSION: The OSCE is an effective method for assessing the clinical competence of medical students. The OSCE could be improved further by modifying the examination questions and promoting effective training for standardized patients and examiners.Tsai JC, Liu KM, Lee KT, Yen JC, Yen JH, Liu CK, Lai CS, Evaluation of the effectiveness of postgraduate general medicine training by objective structured clinical examination-pilot study and reflection on the experiences of Kaohsiung Medical University Hospital, Kaohsiung J Med Sci. 2008 Dec;24(12):627-33.SummaryObjective structured clinical examination (OSCE) is an effective assessment method to evaluate medical students' clinical competencies performance. Postgraduate year 1 (PGY1) residents have been initiated in a general medicine training program in Taiwan since 2003. However, little is known about the learning effectiveness of trainees from this program. This pilot study aimed to evaluate the clinical core competencies of PGY1 residents using OSCE, and to reflect on the strengths and weaknesses of this pilot assessment project. OSCE was conducted for five PGY1 examinees (4 men, 1 woman) with five stations covering core themes, including history taking, physical examination, clinical procedure of airway intubation, clinical reasoning, and communication skills for informing bad news. Itemized checklists and five-point Likert scale global ratings were used for evaluating performance. The results showed that the performance of our PGY1 residents on history taking was significantly better after about 2 months of postgraduate training on general internal medicine. Self-evaluation on performance by examinees revealed significantly lower global ratings on post-course OSCE (4.14 +/- 0.80 vs. 3.68 +/- 0.66; p < 0.02). Surveys from tutors and standardized patients (SPs) completed at pre- and post-course OSCEs showed consistently favorable responses on the purposes, content, process, and environment of this assessment (4.0 +/- 0.17 vs. 4.0 +/- 0.12, nonsignificant). However, a survey of the examinees completed at pre- and post-course OSCEs showed relatively unfavorable responses to the same aspects, and to tutors and SPs (4.1 +/- 0.09 vs. 3.7 +/- 0.18; p < 0.05). Qualitative information revealed that tutors and SPs remarked that PGY1 residents' medical knowledge performance was satisfactory but their clinical reasoning performance, communication skills (giving bad news) and self-confidence were unsatisfactory. In conclusion, this pilot study has demonstrated that OSCE is a rational and feasible assessment method for evaluating the effectiveness of our PGY general medicine training program. The quantitative data and qualitative information provide a foundation to improve the quality of the program design and evaluation in implementing postgraduate general medicine training.