OSCE背景分析

1、文獻(xiàn)蔡淳娟， osce實(shí)務(wù)，臺(tái)北醫(yī)學(xué)大縱市立萬(wàn)芳醫(yī)院，2007:16-21林政勳，客觀結(jié)構(gòu)式教學(xué)測(cè)驗(yàn)評(píng)量於放射技術(shù)學(xué)之應(yīng)用，中臺(tái)科技大學(xué)放射科學(xué)研究所，2011年一月陳柏齡，臨床能力評(píng)介紹，國(guó)立成功大學(xué)醫(yī)學(xué)院附設(shè)醫(yī)院，一般醫(yī)學(xué)訓(xùn)練中心osce整個(gè)概況傳統(tǒng)的醫(yī)學(xué)測(cè)驗(yàn)(如選擇題、口試等)只能評(píng)量考生的醫(yī)學(xué)知識(shí)、以及部分的臨床技術(shù)及解決問題能力，無(wú)法真正反應(yīng)醫(yī)師的臨床技術(shù)能力(尤其是詢問病史、身體檢查等表現(xiàn)能力)1960年代神經(jīng)科醫(yī)師dr. barrows開始使用標(biāo)準(zhǔn)化病人來(lái)教導(dǎo)醫(yī)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(guó)北方丹地大學(xué)教授harden博士等人，首創(chuàng)以客觀結(jié)構(gòu)式臨床技

2、能考試(object structured clinical examination, osce)，論文發(fā)表於br j ed，他們使用標(biāo)準(zhǔn)化病人，以設(shè)計(jì)好的範(fàn)例，具結(jié)構(gòu)式目的，在模仿醫(yī)療現(xiàn)場(chǎng)的考場(chǎng)下，一站站地測(cè)驗(yàn)學(xué)生的臨床技能，評(píng)分者則依據(jù)直接觀察給予考生分?jǐn)?shù)。隨著標(biāo)準(zhǔn)化病人在醫(yī)學(xué)教育上的普遍運(yùn)用，1985年，ian hart及ronald harden 因此在舉行ottawa舉行了assessing clinical competence 研討會(huì)，持續(xù)進(jìn)行至今，成為一個(gè)很重要的世界性醫(yī)學(xué)教育年會(huì)。dr. reznick在siu(southern illinois university)受dr

3、, barrows指導(dǎo)，拿到醫(yī)學(xué)教育碩士，回到加拿大主導(dǎo)medical council of canada(mcc), 1990年加拿大成為世界第一個(gè)將osce納入醫(yī)師執(zhí)照考試的國(guó)家，1994年美國(guó)ecfmg(educational commission for foreign medical graduates)決定使用這種臨床技術(shù)考試來(lái)檢定美國(guó)海外醫(yī)師資格，隔年，美國(guó)國(guó)家醫(yī)師執(zhí)照考試委員會(huì)(nbme, national board of medical examination)，決定在四至七年之間，納入osce測(cè)驗(yàn)。日本於2003起規(guī)定醫(yī)學(xué)生在進(jìn)入臨床實(shí)習(xí)前須通過這種臨床技術(shù)考試，美國(guó)則拖

4、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(dāng)今醫(yī)學(xué)教育上為法被取代的測(cè)驗(yàn)工具，也已經(jīng)在全世界各醫(yī)學(xué)院與教學(xué)醫(yī)院教育中，被普遍用來(lái)測(cè)驗(yàn)醫(yī)師或醫(yī)學(xué)生臨床的技能。 西元1975年英國(guó)北方丹地大學(xué)教授harden博士等人，首創(chuàng)以客觀結(jié)構(gòu)式臨床技能測(cè)驗(yàn)的方法，客觀評(píng)估醫(yī)學(xué)生對(duì)臨床技能的學(xué)習(xí)成效。osce包含三個(gè)主要部分，即模擬醫(yī)療情境、教師客觀評(píng)估、檢討及雙向回饋。(一) 模擬醫(yī)療情境：利用標(biāo)準(zhǔn)化病人，設(shè)計(jì)多應(yīng)(站)臨床教案，每一臨床教案分

5、別測(cè)驗(yàn)醫(yī)學(xué)系學(xué)生某一項(xiàng)(或多項(xiàng))臨床技能，例如：病史詢問、身體檢查、溝通技巧、衛(wèi)生教育、醫(yī)病關(guān)係與技術(shù)操作型技術(shù)等。每一站臨床教案都精心詳細(xì)的規(guī)劃，設(shè)計(jì)出結(jié)構(gòu)清楚的模擬醫(yī)療環(huán)境，且具有明確的測(cè)驗(yàn)?zāi)康摹?二) 教師客觀評(píng)估：評(píng)分教師根據(jù)標(biāo)準(zhǔn)化清單上的項(xiàng)目，客觀地評(píng)估每位醫(yī)學(xué)生在每一臨床教案的表現(xiàn)。(三) 檢討與雙向回饋：測(cè)驗(yàn)完畢後，教師與學(xué)生面對(duì)面檢討測(cè)驗(yàn)中的優(yōu)點(diǎn)及缺失，教師並給予學(xué)生適當(dāng)?shù)闹刚c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(xué)(university of dundee)harden 及gleeson所提出，先由專家編寫出結(jié)構(gòu)式的臨床測(cè)驗(yàn)題目，在向同學(xué)解說及示範(fàn)之

6、後，以受過相關(guān)訓(xùn)練的演員扮演病患(稱為標(biāo)準(zhǔn)化病人standardized patients,簡(jiǎn)稱sps)osce優(yōu)缺點(diǎn)缺點(diǎn)：osce是昂貴的 osce是假的 考生會(huì)洩題 測(cè)驗(yàn)之信度、效度、可行性不易達(dá)到令人滿意的水準(zhǔn)優(yōu)點(diǎn)：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(nèi)容及複雜度可以調(diào)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(cè)驗(yàn)，在相同情境下，面對(duì)相的標(biāo)準(zhǔn)化病人，並且考試的時(shí)間都一樣長(zhǎng)，因此可以減少這種表現(xiàn)型測(cè)驗(yàn)的誤差考生面對(duì)的是不同的站、由不同的考官評(píng)分，因此，不像口試一般，不總成績(jī)不是由單一考給予，而是各站的分?jǐn)?shù)總和，可以減少單一考官個(gè)人主觀意識(shí)的影響。實(shí)施os

7、ce來(lái)客觀評(píng)估臨床技能與態(tài)度，並非完美無(wú)缺，當(dāng)然有優(yōu)缺點(diǎn)，根據(jù)蔡淳娟醫(yī)師分析，優(yōu)缺點(diǎn)如下：優(yōu)點(diǎn)：osce可以評(píng)估學(xué)生的臨床操作技能 osce可以評(píng)估不同程度的臨床問題 各臨床教案內(nèi)容及複雜程度，可依各種教育和考試的需求而加以調(diào)整所有的學(xué)生都接受相同的測(cè)驗(yàn)，在相同的情境下，面對(duì)相同的標(biāo)準(zhǔn)病人或場(chǎng)景，並且使用相同的測(cè)驗(yàn)時(shí)間，因此可以減少表現(xiàn)型測(cè)驗(yàn)的誤差學(xué)生面對(duì)不同的臨床教案，由不同考官評(píng)分，所以不像口試測(cè)驗(yàn)一般，其總成績(jī)不是由單一考官給予，而是各站的考官評(píng)分總和，如此可以減少單一考官個(gè)人主觀意識(shí)的影響。缺點(diǎn)實(shí)施osce需要耗費(fèi)較多資源(包括人力、金錢、時(shí)間及空間等)場(chǎng)景為假的，無(wú)論教案設(shè)計(jì)如何擬真

8、，仍非真實(shí)狀況，尤其因應(yīng)考試需要，臨床技術(shù)常被分割為較小的部分來(lái)測(cè)驗(yàn)考生，因此不易反應(yīng)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(xiàn)型測(cè)驗(yàn)仍然有誤差來(lái)源，其測(cè)驗(yàn)的信度、效度、可行性，並非達(dá)到令人滿意之水準(zhǔn)優(yōu)點(diǎn)：能夠廣泛測(cè)驗(yàn)各種臨床技能時(shí)間、站數(shù)夠多時(shí)信度很高相對(duì)評(píng)估偏差小缺點(diǎn)：需要訓(xùn)練標(biāo)準(zhǔn)病人需動(dòng)員許多教員，複雜且花費(fèi)大選擇性臨床技能測(cè)缺乏給予學(xué)生回饋臨床核心能力評(píng)估學(xué)生臨床的能力病史詢問身體檢查簡(jiǎn)易技巧判讀檢驗(yàn)結(jié)果處理病人狀況溝通態(tài)度及專業(yè)素養(yǎng)是一個(gè)有組織的結(jié)構(gòu)、可融入不同考試的方法黃國(guó)禎，形成性評(píng)量舉總合性評(píng)量，臺(tái)南大學(xué)前言評(píng)量扮演回饋的功能，用

9、來(lái)了解學(xué)生的學(xué)習(xí)成果及調(diào)整或擬訂教師的教學(xué)策略，以達(dá)到最佳的教學(xué)效果(歐滄和，民91概念分析測(cè)驗(yàn) 小測(cè)量評(píng)量 大 範(fàn)圍較廣，以測(cè)驗(yàn)、面談、專案實(shí)作、檔案評(píng)量等方式以診斷學(xué)生的能力，除了評(píng)估學(xué)生能力之外，還包括協(xié)助學(xué)生解決問題評(píng)量目的瞭爾學(xué)生的潛能與學(xué)習(xí)成就，作為判斷學(xué)生努力的程度診斷學(xué)生的學(xué)習(xí)困難與障礙，作為補(bǔ)救教學(xué)及個(gè)別輔導(dǎo)的依據(jù)估量教師教學(xué)的效率，提供教師改進(jìn)教材教法的參考瞭解學(xué)生學(xué)習(xí)進(jìn)步的情形，觸發(fā)學(xué)生的學(xué)習(xí)性趣提供家長(zhǎng)參考，作為瞭解學(xué)生在校學(xué)習(xí)的情形bloom et al.1981對(duì)評(píng)量的看法評(píng)量是一種用以確定學(xué)生學(xué)習(xí)水準(zhǔn)和教學(xué)有效性的證據(jù)的方法評(píng)量包括了比一般期末考試更多種類的證據(jù)評(píng)

10、量是澄清教育的重要目的與教學(xué)目標(biāo)的一種輔助手段，以及確定學(xué)生按這些理想的方式發(fā)展到何種程度的一種過程評(píng)量作為一種回饋-校正系統(tǒng)，在教學(xué)過程的每一步驟判斷該過程是否有效；如果無(wú)效，必須及時(shí)採(cǎi)取什麼變革，以確保過程的有效性評(píng)量是教育研究與實(shí)踐的一種工具，用於查明在達(dá)成某一教育目的時(shí)，不同的歷程是否同樣有效其他學(xué)者對(duì)評(píng)量的看法評(píng)量是運(yùn)用科學(xué)方法和技術(shù)，蒐集有關(guān)學(xué)生學(xué)習(xí)行為及其成就的正確資料，再根據(jù)教學(xué)目標(biāo)，就學(xué)生學(xué)習(xí)表現(xiàn)的情形，予以分析、研究和評(píng)斷的一系列工作評(píng)量係指教師蒐集、綜合、解釋有關(guān)學(xué)生的各種資料，以協(xié)助教師進(jìn)行各種教與學(xué)的歷程黃裕勝，劉敏，黃俊雄，劉克明，高雄醫(yī)學(xué)大學(xué)實(shí)施客觀結(jié)構(gòu)式臨床測(cè)驗(yàn)

11、之經(jīng)驗(yàn)，高雅醫(yī)誌2007；23:161-9摘要客觀結(jié)構(gòu)式臨床測(cè)驗(yàn)(osce)是一種能客觀且公平地評(píng)量醫(yī)學(xué)生臨床技能的評(píng)量工具，目前廣泛應(yīng)用於世界各國(guó)的醫(yī)學(xué)教育。然而，臺(tái)灣大部分的醫(yī)學(xué)院才剛開始採(cǎi)用osce來(lái)評(píng)量學(xué)生能力。高雄醫(yī)學(xué)大學(xué)在2003年建立了臺(tái)灣第一個(gè)標(biāo)準(zhǔn)化病人計(jì)劃，並且將標(biāo)準(zhǔn)化病人應(yīng)用於osce。此文章敘述本校實(shí)行osce的過程，從資料蒐集、參觀國(guó)外臨床技能中心、咨詢外國(guó)醫(yī)學(xué)教育專家、舉辦國(guó)際研討會(huì)、設(shè)立osce委員會(huì)、編寫個(gè)案及訓(xùn)練標(biāo)準(zhǔn)化病人，到實(shí)際實(shí)施osce及調(diào)查學(xué)生意見。大部分學(xué)豆對(duì)於測(cè)驗(yàn)感到滿意，並覺得這是很好的學(xué)習(xí)經(jīng)驗(yàn)。基於本次經(jīng)驗(yàn)，osce委員會(huì)決定採(cǎi)用osce做為評(píng)估

12、醫(yī)學(xué)生臨床能力的方法之一。osce除了廣用於評(píng)量醫(yī)學(xué)生之外，亦被用於評(píng)量牙醫(yī)系 、護(hù)理系、藥學(xué)系等醫(yī)學(xué)相關(guān)科系的學(xué)生，因此，我們將醫(yī)學(xué)系實(shí)施osce的經(jīng)驗(yàn)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 ca

13、n 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 o

14、n 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 t

15、he 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 w

16、ith 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 201

17、0;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 firs

18、t 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, respecti

19、vely. 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 stud

20、ents 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 reliabili

21、ty analysis was conducted of the 2007 osce questions. the overall score and reliability (cronbachs 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 rel

22、iability 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 e

23、ffective 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 eff

24、ectiveness 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 effectiv

25、e 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 pilo

26、t 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, physi

27、cal 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

28、 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 respo