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1、http:/www.vghks.gov.tw/臨床教學回饋技巧臨床教學回饋技巧與能力評估與能力評估呂志成內科部 一般內科九十六年七月http:/www.vghks.gov.tw/資料來源資料來源96.5.1516臨床教學技巧與技能評估工作坊 Teaching The Teachers (NHS)96.5.2627南區導師研習營 台大家醫科梁繼權副教授96.6 台北榮總學訊 程雅琳與陳祖裕96.7.7 一般醫學內科訓練示範中心研討會Proverbs about Medical Education, Beverly Henry, PhD, 2002http:/www.vghks.gov.tw/主要
2、話題主要話題教學的挑戰臨床教學回饋技巧能力評估http:/www.vghks.gov.tw/A Doctor is a TeacherA Doctor is a TeacherElizabeth Armstrong, Harvard Medical InternationalHealthcare professionals educate their patients,students and colleagues as an integral part of their professional lives, yet.education is typically not addressed
3、during any part of their traininghttp:/www.vghks.gov.tw/教學的目的教學的目的Is create effective learningComponentsLearnersEducatorsEffective learning environmenthttp:/www.vghks.gov.tw/Winston Churchill, 1874-1965Winston Churchill, 1874-1965Personally I am always ready to learn, although I do not always like b
4、eing taughthttp:/www.vghks.gov.tw/主要話題主要話題教學的挑戰臨床教學回饋技巧能力評估http:/www.vghks.gov.tw/學習評量學習評量(Evaluation)(Evaluation)發展式評量(Formative Evaluation) 回饋總結式評量(Summative Evaluation) 考試http:/www.vghks.gov.tw/回饋回饋 Feedback Feedback新心理療法 - 一個人對另一個人言行的反應工程學 - 系統為達成目標需做調整時所蒐集的資訊，以致導向火箭的發展http:/www.vghks.gov.tw/回饋回
5、饋 生活的例子生活的例子練習小提琴的時候，琴弦發出的聲音是調整拉弓與按弦的依據，這種回饋是自動產生的當幼兒呀呀學語時，父母的表情、笑容及親吻，是幼兒學習的最大鼓勵。然而這種回饋是人為給予的http:/www.vghks.gov.tw/控制論控制論(cybernetics)(cybernetics)控制論之父Norber Weiner (18941964)認為回饋是將運作的結果再注入系統中以達到控制系統的目的，這過程成了一種學習內分泌系統是個例子http:/www.vghks.gov.tw/看不到的回饋看不到的回饋(Vanishing Feedback)(Vanishing Feedback)回
6、饋雖然是學習活動中重要的一環，但醫學教育卻常常缺乏正面的回饋有些老師怕回饋傷害學習者，就用一些間接或模稜兩可的方式來回饋 這就是看不到的回饋http:/www.vghks.gov.tw/Old English ProverbOld English ProverbSee oneDo oneTeach onehttp:/www.vghks.gov.tw/A Wiser Chinese ProverbA Wiser Chinese ProverbTell me, I will forgetHearShow me, I will rememberSeeInvolve me, I will unders
7、tandDohttp:/www.vghks.gov.tw/有效的回饋有效的回饋觀察分析提出建議訂定改善目的與方法追蹤結果http:/www.vghks.gov.tw/有效的回饋技巧有效的回饋技巧 1/2 1/2建立適當的人際間相處氣氛適合的地點建立相互認同的學習目標瞭解學習者的看法與感受針對客觀的明顯行為Lindsay Hewson 1998http:/www.vghks.gov.tw/有效的回饋技巧有效的回饋技巧 2/2 2/2用非批判性的態度與語言針對特定行為提出意見給予適當的回饋提出具有建設性的改善意見Lindsay Hewson 1998http:/www.vghks.gov.tw/F
8、eedback SandwichFeedback SandwichGive positive comments initiallyAsk what went well and what went less well Ask How could improve the less well stagesGive some practical or helpful tipsHighlight other aspects which could be improved Arrange another assessment after more practiceEnd by positive feedb
9、ack on things the student did well Scottish Council for Postgraduate Medical and Dental Educationhttp:/www.vghks.gov.tw/需要回饋的臨床能力需要回饋的臨床能力專業倫理醫病溝通同儕溝通理學檢查http:/www.vghks.gov.tw/主要話題主要話題教學的挑戰臨床教學回饋技巧能力評估http:/www.vghks.gov.tw/評估的目的評估的目的科學本身就是建立在不斷評估與改進的架構上，評估可以說是一切科學活動的基礎臨床能力評估為幫助醫學生與住院醫師學習醫學的知識與技能醫療
10、機構評鑑與住院醫師升遷最終提升病患照顧品質http:/www.vghks.gov.tw/評估評估老師根據教育的目的，對學習者的知識、技巧與態度的評價過程評估是目的導向的學習的能力與程度則應於評估前決定http:/www.vghks.gov.tw/臨床能力臨床能力以病患最佳的利益為考量正確的醫療決定與病患及其他醫療人員有效率的互動這種能力需終身維持與表現出來http:/www.vghks.gov.tw/能力金字塔能力金字塔Knows 筆試Know How 臨床反應Show How OSCEDoes - Portfolios認知行為http:/www.vghks.gov.tw/4 Stages o
11、f Competence4 Stages of CompetenceUnconscious incompetenceConscious incompetenceConscious competenceUnconscious competencehttp:/www.vghks.gov.tw/臨床核心能力的範疇臨床核心能力的範疇能力為基礎的教育(competency-based medicine)已逐漸成為醫學教育的主流Brown university 九項醫學生核心能力ACGME六種核心能力為ABMS採用使能力為基礎的教育由住院醫師訓練推展到醫師繼續教育http:/www.vghks.gov.t
12、w/Nine Core AbilitiesNine Core AbilitiesMD 2000 中寫著 The Habits of the Head and HeartMD2000.doc. Http:/bms.brown.edu/, 2007http:/www.vghks.gov.tw/布朗大學核心課程布朗大學核心課程 1/2 1/2Effective Communication Basic Clinical Skills Using Basic Science in the Practice of Medicine Diagnosis, Management, & Prevention L
13、ifelong Learning MD2000.doc. Http:/bms.brown.edu/, 2007http:/www.vghks.gov.tw/布朗大學核心課程布朗大學核心課程 2/2 2/2Self-awareness, Self-care, and Personal Growth The Social and Community Contexts of Health CareMoral Reasoning and Clinical Ethics Problem Solving MD2000.doc. Http:/bms.brown.edu/, 2007http:/www.vgh
14、ks.gov.tw/ACGMEACGME核心能力核心能力美國 Accreditation Council for Graduate Medical EducationMedical knowledgePatient carePractice-based learning and improvementInterpersonal and communication skillsProfessionalismSystem-based practicehttp:/www.vghks.gov.tw/醫學知識醫學知識具備已有的與發展中的知識生物醫學、臨床醫學與社會科學照顧病人和教育他人傳統被動式評估如晨
15、會、討論會等http:/www.vghks.gov.tw/醫學知識評估方法醫學知識評估方法訓練中測驗 (In-Training Examination, ITE)病歷誘導回顧 (Chart Stimulated Recall Oral Examination, CSR)多詢問高層次認知能力的問題，以了解學員為貧乏者、散亂者、推論者或貫通者http:/www.vghks.gov.tw/病人照顧病人照顧基本資料蒐集能力醫療建議能力建立處置計劃、談判與執行及病人照顧的整合能力教師需接受直接觀察及評分的訓練http:/www.vghks.gov.tw/病人照顧評估方法病人照顧評估方法Direct Ob
16、servation Mini-Clinical Examination Exercise (mini-CEX)Direct Observation of Competency (DOC) TrainingBehavior Observation Training (BOT)Performance Dimension Training (PDT)Frame of Reference Training (FRT, FOR)http:/www.vghks.gov.tw/人際與溝通技巧人際與溝通技巧建立與維繫醫病關係的基礎與病患、家屬與醫療同儕利用傾聽、詢問、非語言及描述等方式http:/www.vg
17、hks.gov.tw/人際與溝通技巧評估方法人際與溝通技巧評估方法Standardized patientVideotape reviewMini-CEX查核表評量法 (Checklist Evaluation-Live/Recorded Performance) 360度評量法 ( 360-Degree Evaluation Instrument)http:/www.vghks.gov.tw/專業態度專業態度持續專業發展的職志執行合乎醫療倫理的行為瞭解事物的多樣性維持事物的敏感度對病人、專業與社會負責任http:/www.vghks.gov.tw/專業態度評估方法專業態度評估方法Direct
18、 Observation360度評量法 ( 360-Degree Evaluation Instrument)Scale to MeasureProfessional attitudes and behaviorshttp:/www.vghks.gov.tw/系統為基礎的醫療系統為基礎的醫療醫療決策與執行受到醫療體系與環境影響瞭解醫療體系改善環境促進醫療品質http:/www.vghks.gov.tw/系統為基礎的醫療評估方法系統為基礎的醫療評估方法Medical records audit學習分析並解決醫療問題 PDSA cycle - plan 、do 、 study and acthtt
19、p:/www.vghks.gov.tw/執業基礎的學習與改進執業基礎的學習與改進實證醫學的訓練可採用獨立式的實證醫學課程 (freestanding EBM curriculum)選取住院醫師有興趣的題目教學與日常診療工作結合建立終身學習教師要以身作則http:/www.vghks.gov.tw/執業基礎的學習與改進評估方法執業基礎的學習與改進評估方法Fresno test (EBM)Berlin Questionnaire (sleep apnea synd.)OSCEBirmingham QuestionnairePortfolioshttp:/www.vghks.gov.tw/評估易生的
20、錯誤評估易生的錯誤仁慈的錯誤(Leniency Error)嚴苛的錯誤(Severity Error)光環(月暈)效應 (Halo Effect) 偏見第一印象錯誤(First Impression Error)交情偏差(Friendship Bias)http:/www.vghks.gov.tw/Not every scholar can keep up with developments in his or her field, maintain an enthusiastic attitudetoward learning and inspire otherswith that enth
21、usiasm. Those who can, teach.Saul ME. The New York Times, April 3, 1988, Section IV, 16.http:/www.vghks.gov.tw/Take Home MessageTake Home Message教學的目的是為創造有效的學習回饋的過程是一種學習有效的回饋 三明治原理Brown university 九項醫學生核心能力ACGME六種核心能力選擇適當的方式來評估能力http:/www.vghks.gov.tw/http:/www.vghks.gov.tw/K8H5E2A+x(u$rZnWkThPeMbJ7
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25、t!pYmUjRgOcL9I6E3B+y(v%r#oXlTiQeNbK8G5D2A-x*t$qZnVkShPdMaI7F4C0z)w&s!pXmUjRfOcL9H6E3B+y(u%r#oWlTiQeNbJ8G5D1A-x*t$qYnVkSgPdMaI7F3C0z)v&s!pXmUiRfOcK9H6E2B+x(u%rZoWlThQeMbJ8G4D1A-w*t$qYnVjSgPdLaI7F3C0y)v&s#pXmUiRfNcK9H5E2B+x(u$rZoWkThQeMbJ7G4D1z-w*t!qYmVjSgOdLaI6I6F3B0y)v%s#pXlUiQfNcK8H5E2A+x*u$rZnWkTh
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27、+x(u%rZoWkThQeMbJ8G4D1z-w*t!qYnVjSgOdLaI6F3C0y)v%s#pXlUiRfNcK8H5E2A+x(u$rZnWkThPeMbJ7G4C1z-w&t!qYmVjRgOdL9I6F3B0y)v%s#oXlUiQfNcK8H5D2A+x*u$rZnWkShPeMaJ7G4C1z)w&t!pYmVjRgOcL9I6E3B0y(v%r#oXlTiQfNbK8G5D2A-x*u$qZnWkShPdMaJ7F4C1z)w&s!pYmUjRgOcL9H6E3B+y(v%r#oWlTiQeNbK8G5D1A-x*t$qZnVkSgPdMaI7F4C0z)v&s!pXmU
28、jRfOcL9H6E2B+y(u%r#oWlThQeNbJ8G5D1A-w*t$qYnVkSgPdLaI7F3C0z)v&s#pXmUiRfOcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1z-w*t!qYnVjSgPdLaI6F3C0y)v&s#pXlUiRfNcK9H5E2A+x(u$rZoWkThPeMbJ7G4D1z-w&t!qYmVjSgOdL9I6F3B0y)v%s#oXlUiQfNcK8H5E2A+x*u$rZnWkThPeMaJ7J7G4C1z-w&t!pYmVjRgOdL9I6E3B0y(v%s#oXlTiQfNbK8H5D2A-x*u$qZnWkShPdMaJ7
29、F4C1z)w&s!pYmUjRgOcL9H6E3B+y(v%r#oXlTiQeNbK8G5D2A-x*t$qZnVkShPdMaI7F4C0z)w&s!pXmUjRfOcL9H6E2B+y(u%r#oWlThQeNbJ8G5D1A-w*t$qYnVkSgPdMaI7F3C0z)v&s!pXmUiRfOcK9H6E2B+x(u%rZoWlThQeMbJ8G4D1A-w*t!qYnVjSgPdLaI6F3C0y)v&s#pXlUiRfNcK9H5E2A+x(u$rZoWkThQeMbJ7G4D1z-w*t!qYmVjSgOdLaI6F3B0y)v%s#pXlUiQfNcK8H5E2A+x*u$r
30、ZnWkThPeMaJ7G4C1z-w&t!pYmVjRgOdL9I6F3B0y(v%s#oXlUiQfNbK8H5D2A+x*u$qZnWkShPeMaJ7F4C1z)w&t!pYmUjRgOcL9I6E3B+y(v%r#oXlTiQeNbK8G5D2A-x*u$qZnVkShPdMaJ7F4C0z)w&s!pYmUjRfOcL9H6E3B+y(u%r#oWlTiQeNbJ8G5D1A-x*t$qYnVkSgPdMaI7F3C0z)v&s!pXmUiRfOcK9H6E2B+y(u%rZoWlThQeNbJ8G4D1A-w*t$qYnVjSgPdLaI7F3C0y)v&s#pXmUiRfNcK
31、9H5E2B+x(u$rZoWkThQeMbJ7G4D1z-w*t!qYnVjSgOdLaI6F3C0y)v%s#pXlUiRfNcK8H5E2A+x(u$rZnWkThPeMbJ7G4C1z-w&t!qYmVjRgOdL9I6F3B0y(v%s#oXlUiUiQfNbK8H5D2A+x*u$qZnWkShPeMaJ7G4C1z)w&t!pYmVjRgOcL9I6E3B0y(v%r#oXlTiQfNbK8G5D2A-x*u$qZnVkShPdMaJ7F4C0z)w&s!pYmUjRfOcL9H6E3B+y(v%r#oWlTiQeNbK8G5D1A-x*t$qZnVkSgPdMaI7F4C0z)
32、v&s!pXmUjRfOcK9H6E2B+y(u%rZoWlThQeNbJ8G4D1A-w*t$qYnVjSgPdLaI7F3C0z)v&s#pXmUiRfOcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1z-w*t!qYnVjSgOdLaI6F3C0y)v%s#pXlUiRfNcK8H5E2A+x(u$rZoWkThPeMbJ7G4D1z-w&t!qYmVjSgOdL9I6F3B0y)v%s#oXlUiQfNcK8H5D2A+x*u$rZnWkShPeMaJ7G4C1z)w&t!pYmVjRgOcL9I6E3B0y(v%s#oXlTiQfNbK8H5D2A-x*u$qZnWkSh
33、PdMaJ7F4C1z)w&s!pYmUjRgOcL9H6E3B+y(v%r#oWlTiQeNbK8G5D1A-x*t$qZnVkShPdMaI7F4C0z)w&s!pXmUjRfOcL9H6E2B+y(u%r#oWlThQeNbJ8G5D1A-w*t$qYnVkSgSgPdLaI7F3C0z)v&s#pXmUiRfOcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1A-w*t!qYnVjSgPdLaI6F3C0y)v&s#pXlUiRfNcK9H5E2A+x(u$rZoWkThPeMbJ7G4D1z-w&t!qYmVjSgOdL9I6F3B0y)v%s#pXlUiQfNcK8H5E
34、2A+x*u$rZnWkThPeMaJ7G4C1z-w&t!pYmVjRgOdL9I6E3B0y(v%s#oXlTiQfNbK8H5D2A-x*u$qZnWkShPeMaJ7F4C1z)w&t!pYmUjRgOcL9I6E3B+y(v%r#oXlTiQeNbK8G5D2A-x*t$qZnVkShPdMaI7F4C0z)w&s!pXmUjRfOcL9H6E2B+y(u%r#oWlTiQeNbJ8G5D1A-x*t$qYnVkSgPdMaI7F3C0z)v&s!pXmUiRfOcK9H6E2B+x(u%rZoWlThQeMbJ8G4D1A-w*t!qYnVjSgPdLaI7F3C0y)v&s#pX
35、mUiRfNcK9H5E2B+x(u$rZoWkThQeMbJ7G4D1z-w*t!qYmVjSgOdLaI6F3B0y)v%s#pXlUiQfNcK8H5E2A+x*u$rZnWnWkThPeMaJ7G4C1z-w&t!qYmVjRgOdL9I6F3B0y(v%s#oXlUiQfNbK8H5D2A+x*u$qZnWkShPeMaJ7F4C1z)w&t!pYmUjRgOcL9I6E3B+y(v%r#oXlTiQfNbK8G5D2A-x*u$qZnVkShPdMaJ7F4C0z)w&s!pYmUjRfOcL9H6E3B+y(u%r#oWlTiQeNbJ8G5D1A-x*t$qYnVkSgPdMa
36、I7F3C0z)v&s!pXmUjRfOcK9H6E2B+y(u%rZoWlThQeNbJ8G4D1A-w*t$qYnVjSgPdLaI7F3C0y)v&s#pXmUiRfNcK9H5E2B+x(u$rZoWkThQeMbJ8G4D1z-w*t!qYnVjSgOdLaI6F3C0y)v%s#pXlUiRfNcK8H5E2A+x(u$rZnWkThPeMbJ7G4C1z-w&t!qYmVjRgOdL9I6F3B0y(v%s#oXlUiQfNcK8H5D2A+x*u$rZnWkShPeMaJ7G4C1z)w&t!pYmYmVjRgOcL9I6E3B0y(v%r#oXlTiQfNbK8G5D2A-x
37、*u$qZnVkShPdMaJ7F4C0z)w&s!pYmUjRgOcL9H6E3B+y(v%r#oWlTiQeNbK8G5D1A-x*t$qZnVkSgPdMaI7F4C0z)v&s!pXmUjRfOcK9H6E2B+y(u%rZoWlThQeNbJ8G4D1A-w*t$qYnVkSgPdLaI7F3C0z)v&s#pXmUiRfOcK9H5E2B+x(u%rZoWkThQeMbJ8G4D1z-w*t!qYnVjSgOdLaI6F3C0y)v%s#pXlUiRfNcK9H5E2A+x(u$rZoWkThPeMbJ7G4D1z-w&t!qYmVjSgOdL9I6F3B0y)v%s#oXlUiQfNcK8H5D2A+x*u$rZnWkShPeMaJ7G4C1z-w&t!pYmVjRgOdL9I6E3B0y(v%s#oXlTiQfNbK8H5D2A-x*u$qZnWkWkShPdMaJ7F4C1z)w&s!pYmUjRgOcL9H6E3B+y(v%r#oWlTiQeNbK8G5D1A-x*t$qZnVkShPdMaI7F4C0z)w&s!p
