類別:

針對診斷為高血脂的病人，醫病共享決策與服藥順從性之間的關係

Sat, 01 Jan 2022 00:00:00 GMT

標題: 針對診斷為高血脂的病人，醫病共享決策與服藥順從性之間的關係; Examining the association between shared decision-making and medication adhesion 作者: Ying-Na Hsiao; 蕭吟娜摘要: 背景介紹服藥順從性指的是，病患是否按醫師處方規定次數服用藥物，以及他們是否持續照醫師處方服用藥物，好的服藥順從性比起新型的治療方法更能增進病人的健康。影響服藥順從性的因素有很多面項，病人、藥物、看診醫師及一些系統性因素等皆會影響服藥順從性。增加服藥順從性的策略也有很多，舉凡病人教育、藥物管理及認知行為療法等等策略。近年來醫病關係變化，醫師不再像過去是主要的單一決策者，醫病共享決策此種以病人為中心的看診模式更逐漸被提倡，而認知行為的介入方式也漸被納入探討其和服藥順從性的關聯性。由過去的文獻回顧可以發現，醫病共享決策對於高血壓的病人可以增加其服藥順從性，但對於糖尿病的病人卻沒有辦法增加其服藥順從性，且主動式及共享式的醫病決策關係比起較為被動式的醫病決策關係更能增加病人的服藥順從性。然而過去的文獻較少提到醫病共享決策對於高血脂病人其服藥順從性是否有影響。過去的研究也顯示，對於高血脂症或其他慢性疾病的病人而言，高服藥順從性的病人比低服藥順從性的病人增加了 26%健康狀況的改善。因此可以知道，好的服藥順從性對於高血脂症的病人來說可以有較好的健康狀況，也因此增加高血脂症病人的服藥順從性是至關重要的議題。因此，本研究針對高血脂病人去探討醫病共享決策是否會影響其服藥順從性。研究方法與材料本研究的受試者來自於臺大醫院金山分院門診病人。我們收集 182 例於門診具備高血脂診斷的病人，請病人於看診結束後填答問卷，請病人填寫自覺其看診時和醫生之間的醫病關係為何種醫病共享決策關係，共分成五個層次的醫病共享決策關係分別對應不同的醫病共享決策模式(主動式、被動式、共享式)，排除一例於醫病共享決策題目填錯答案者，排除 29 例於宗教信仰、婚姻狀態、醫療保險、月收入、疾病嚴重度等未填答完整有缺漏者，最終可納入分析之個案為 152 人。年齡分佈從 27 歲到 94 歲，平均年齡 64.1 歲，女性 92 位，男性 60 位。服藥順從性的部份則是用藥物持有率來計算，藥物持有率越高表示其服藥順從性越好。本研究以簡單及多重迴歸分析來探討藥物持有率及醫病共享決策之關係，並探討問卷中各個變項和藥物持有率之關聯性。結論本研究之結果顯示，對於高血脂的病人而言，醫病共享決策並無法增加病人的服藥順從性，對於高血脂的病人來說，影響其服藥順從性的因素為月收入差異和不同的門診醫師，月收入高的病人其服藥順從性相對較差，而不同門診醫師之間即便醫病共享決策的方式類似，仍存在不同的服藥順從性差異，故不同門診醫師對病人服藥順從性的影響仍需待後續研究加以深入探討。; Introduction Medication adherence refers to whether patients take the medication as prescribed by the physician. Good medication adherence can improv the patients health more than new treatment methods. There are many factors that affect medication adherence. Patients , drugs, physicians, and some systemic factors can all affect medication adherence. There are also many strategies to increase medication adherence, such as patient education, medication management, and cognitive behavioral therapy. In recent years, the doctor-patient relationship has changed. Physicians are no longer the main decision-makers as in the past. The concept of shared decision making between doctors and patients is gradually being promoted, and this cognitive behavioral intervention had gradually been included to explore its relationship with medication adherence. From the literature review , it can be found that the policy of shared decision making can increase the medication adherence rate among patients with Hypertension, but it cannot increase the medication adherence rate among patients with Diabetes mellitus. Compared with passive shared decision making policy, active and shared decision making policy increased medication adherence rate . However, previous literatures seldom mentioned about whether the policy of shared decision making affects the medication adherence rate among patients with hyperlipidemia. Previous studies have also shown that for patients with hyperlipidemia or other chronic disease, patients with high medication adherence rate increased their health status by 26% compared with those with low medication adherence rate. Therefore, it can be known that good medication adherence can lead to better health status for patients with hyperlipidemia. It is important to increase the medication adherence rate among patients with hyperlipidemia. Therefore, our study aimed at examining the association between shared decision making policy and medication adherence among patients with hyperlipidemia. Material and Method The subjects of this study were enrolled from outpatient clinics from the Jinshan Branch of National Taiwan University Hospital. We collected 182 participants who were diagnosed with hyperlipidemia in the outpatient clinic. The patients were asked to fill in the basic questionnaires after visiting the outpatient clinic, and the patients were asked to fill in what they think about the doctor-patient relationship during this outpatient clinic. The relationship was divided into five levels according to the questionnaires. The decision making relationships correspond to three different decision making modes(active, passive and shared). One case was excluded due to wrong answer about the questionnaires of shared decision making, and 29 cases were excluded due to wrong answer or unanswered about the questions related to religion, marital status, medication insurance, monthly income, and disease severity. There were 152 cases that could be finally included in the analysis. The age of patients ranged from 27 to 94 years old, with an average age of 64.1 years, 92 females and 60 males. The medication adherence rate is calculated by the Medication Possession ratio(MPR). The higher the Medication Possession ratio(MPR) means the better the medication adherence rate. Our study use simple and multiple linear regression analysis to analyze the relationship between Medication Possession ratio(MPR) and shred decision making. Our study also analyze the relationship between each variable in the questionnaire and Medication Possession ratio(MPR). Conclusion The result of this study show that for patients with hyperlipidemia, the policy of shared decision making cannot increase the medication adherence rate. Factors that affect the medication adherence rate are differences in monthly income and different outpatient physicians. Patients with higher monthly income have poor medication adherence rate. Even if similar policy of shared decision making among different outpatients physicians, there are still differences in medication adherence rates. It still need further research about the influence of different outpatients physicians on medication adherence rate .

醫學人文學習動機之影響因素：科系、性別與知識信念

Fri, 01 Jan 2021 00:00:00 GMT

標題: 醫學人文學習動機之影響因素：科系、性別與知識信念; "The Factors Associated with the Motivation to Learning Medical Humanities: Major, Gender, and Epistemic Beliefs" 作者: Yu-Ting Tsao; 曹玉婷摘要: "「醫學人文」是在醫學教育範疇內一個重要領域，研究顯示，接觸醫學人文可幫助醫師、醫學生來應對壓力、減少倦怠，培養韌性和促進幸福感。學生的「知識信念」，也就是學生如何看待知識、獲取知識、建構自己的知識體系，會影響學生的學習成效、學習方法，包含他們的學習動機。本研究以問卷調查為基礎，使用修改後的醫學知識信念量表，研究對象為台大醫學院醫學人文課程的一年級學生。以學生參與醫學人文課程的體驗式學習活動次數多寡來表示其具有深度學習動機（參與次數多，致力於學習）或淺層學習動機（參與次數少，以合格為目標）。以探索性因素分析驗證本研究問卷的建構效度，並計算Cronbach’s α值以檢驗每個構面的內部一致性信度。以獨立樣本t檢定、卡方檢定，及多變數邏輯回歸分析等統計方法，探討學生的知識信念、科系、性別，與學習動機之關聯。本研究共收集172份有效問卷，其中130位參與者是醫學系學生（75.58％），42位參與者是非醫學系學生（24.42%），有110位是男性（63.95％），62位是女性。研究結果發現，與非醫學系學生相比，醫學系學生更不可能具有深度學習動機（調整勝算比= 0.29, p = 0.02），對醫學知識的確定性抱持簡單信念者，更不可能具有深度學習動機（調整勝算比= 0.43, p = 0.04），對醫學專家的可性度抱持簡單信念者，更可能具有深度學習動機（調整勝算比= 2.30, p = 0.01）。男醫學生比女醫學生更不可能具有深度學習動機（調整勝算比= 0.26, p = 0.01）。本研究的貢獻在於驗證醫學知識信念問卷之信效度，可提供日後相關研究使用，並發現在醫學人文課程，學生的知識信念、科系，與性別，都是學習動機的影響因子，建議第一線教師及課程制定者，能留意這些因素在醫學人文教育中的角色，營造合適的教學環境，深化學生對醫學人文的學習動機。"

運用高擬真模擬假人系統於見習醫學生之兒童初始評估及基本救命術教學

Fri, 01 Jan 2016 00:00:00 GMT

標題: 運用高擬真模擬假人系統於見習醫學生之兒童初始評估及基本救命術教學; Application of high fidelity patient simulator in the teaching of pediatric initial assessment and basic life support to medical clerks 作者: Yu-Chun Chiu; 邱郁淳摘要: 研究背景及目的情境模擬(simulation)訓練在臨床醫學的進階訓練中是很受歡迎的教學方式，並被認為可以減少學習過程中出現的醫療失誤。兒童醫療的初學者往往對於評估和處理兒童患者覺得陌生且缺乏信心，因此，本研究的目的在探討以高擬真情境模擬假人(high-fidelity patient simulator)系統介入的醫學情境模擬訓練在醫學生實習醫學生教學的可行性，及此教學方式是否能幫助實習醫學生學習對病童的初步評估和處置。研究方法研究對象為從2014.09至2015.08在台大醫院小兒部實習的台大醫學系五年級實習醫學生共141名。每一梯次的學生被平均分成兩組，對照組為常規教學組S(-)接受以病童影片及急救教學模具輔助的兒童評估三角(Pediatric assessment triangle, PAT)初始評估、初步處置及基本教命術(Basic life support, BLS)教學；研究組為情境模擬教學組S(+)在常規課程後增加30分鐘以高擬真情境模擬假人系統介入的情境模擬練習並加上教師及同儕的討論回饋。一共有三位教師輪流參與課程。學生於課前課後皆填寫評量病童評估、處置之能力與信心的自評問卷，並在課後問卷中調查對課程的滿意度及課程對其學習助益。各問題的答案以李克特量表(Likert scale)1至5分表示，分數愈高表示愈同意，當問卷中所有問題皆為同樣答案時被定義為無效問卷。經卡方檢定(Chi-square test)、學生t檢定(Student t test)、變異數分析(Analysis of variance, ANOVA)及線性回歸分析(Linear regression)等統計方法分析，p值<0.05定義為具有統計上顯著的差異。研究結果共有141名學生填寫問卷，其中有108份(76.6％)有效問卷。S(-)組有44位學生而其中的37份為有效問卷；S(+)組有97位學生而其中的71份為有效問卷。在所有的學生中，課前愈同意模擬教學能增加其學習動機者，在課後愈覺得此課程對其學習有助益(p值<0.01)。針對學員課前問卷對「模擬教學能增加學習動機」的看法，課前Likert scale>3分的學生比≦3分的學生課後更同意「此課程對學習有助益」(4.55分 v.s. 4.31分，p值= 0.04)。此外，在課後「整體臨床能力」較課前分數進步≧2分的學生中，課前「整體臨床能力」與課後「此課程對學習有助益」的Likert scale分數有臨界值的相關性(p值= 0.06)；但對其中S(+)組的學生來說，則達到統計上顯著的相關性，當學生的課前「整體臨床能力」分數愈高，課後愈覺得「這堂課對學習有助益」(p值= 0.03)。討論高擬真情境模擬訓練是一種受歡迎和有趣的學習/教學方法，並可以減少訓練過程中出現的醫療失誤。在本研究中，以高擬真情境模擬假人系統介入教學的S(+)組學生滿意度和S(-)組一樣好，S(+)組其課後學習助益的評價則較S(-)組稍高但尚未達到統計學上顯著的差異。經進一步統計分析證實，愈符合學習者興趣引發學習動機的教學方式愈能提高其課後的課程滿意度和學習成效。此外，課前愈具備先備知識能力的學習者，愈能在課程內獲得良好學習成效。結論運用高擬真情境模擬假人系統介入的情境模擬教學做為醫學系實習醫學生的臨床教育，為一具體可行的教學模式，且課後學員滿意度及對學習助益的評價高；此外，此教學方式對於課前學習動機或先備知識能力較高的學生教學成效更高。; Background and Aim Simulation is popular in advanced clinical training and considered to reduce errors made during learning. Medical beginners feel more unfamiliar in assessing and managing the pediatric patients. This study aims to explore the feasibility of using high-fidelity patient simulator in the teaching of medical clerks , and whether this new course helps them to learn the initial assessment and management for the sick children. Material and Method A total of 141 fifth-year medical students rotated pediatric clerkship in National Taiwan University Hospital from Sep.2014 to Aug.2015 were enrolled. Students were separated into two groups. Students in the conventional group S(-) received video and teaching aid-assisted teaching of pediatric initial assessment, initial management and basic life support(BLS). Students in the simulation group S(+) had an additional 30-minutes of practice and debriefing with high-fidelity infant simulator after the conventional course. There were 3 teachers involved in this course. The self-evaluated ability and confidence for pediatric patient assessment and management, the attitude for learning, and the evaluation and satisfaction for this course were evaluated by pre and post-course questionnaires which were not included into the semester score. The answer of each questions were scored with Likert scale 1 to 5. The questionnaire with all the questions have same answers of Likert scale was defined as invalid questionnaire. Data of the questionnaires were analyzed by Chi-square test, Student t test, Analysis of variance(ANOVA) and Linear regression. A p value<0.05 was considered statistically significant. Result One hundred and forty-one students were enrolled with 108 (76.6%) questionnaires were valid. Forty-four students were in the S(-) group and 37 valid questionnaires were obtained. Ninety-seven students were in the S(+) group and 71 valid questionnaires were obtained. For all students , the pre-course scale of “simulation increases learning motivation” had positive association with the scale of “this course is helpful for learning” (p value <0.01) after the course. Students who have scale of pre-course “simulation increases motivation” >3 stated significantly higher score for ‘this course is helpful for learning’ (4.55 v.s. 4.31, p value=0.04). In addition, for students with “overall clinical capacity” scale improvement≧2, the pre-course scale of“overall clinical capacity”had borderline association with the agreement of “this course is helpful for learning” (p value=0.06) but had significant association specifically for students in the S(+) group (p value=0.03). Students who stated higher scale of pre course “overall clinical capacity’, scored higher scale of “this course is helpful for learning”(p value=0.03) after the course. Discussion High-fidelity simulation is a popular and interesting learning / teaching method which reduces error made in training. In this study, the student satisfaction was high in both group. The rating of “this course is helpful for learning” was higher in the S(+) group but had not reached statistically significance. Supported by further analysis, the learning / teaching method meets the learner’s preference and leads to learning motivation is crucial for the course satisfaction and good learning outcome. Moreover, the learner’s prior knowledge and ability are important for gaining learning effectiveness. Conclusion High-fidelity patient simulator-assisted teaching is a feasible teaching method in the training of medical clerks and the student’s satisfaction is high. Besides, simulation is more beneficial in the teaching of students with active motivation or having prior knowledge and ability.

運用遊戲式學習於醫學生兒童發展課程：遊戲元素與學習成效之探討

Wed, 01 Jan 2025 00:00:00 GMT

標題: 運用遊戲式學習於醫學生兒童發展課程：遊戲元素與學習成效之探討; Applying Game-based Learning in a Child Development Course for Medical Students: An Exploration of Game Elements and Learning Outcomes 作者: 田智瑋; Chih-Wei Ten 摘要: 正確掌握兒童發展里程碑與及時辨識發展遲緩，已被美國小兒科醫學生教育委員會與英國皇家兒科與兒童健康學院列為醫學生核心學習目標。在我國從醫學生、畢業後一般醫學訓練到兒科專科醫師訓練，兒童發展都被列為重要的學習項目。早期偵測並介入兒童發展異常亦是我國臨床醫療的重要任務。惟現行醫學生多以短期背誦學習，成效有限。本研究以桌遊進行遊戲式學習，期望強化學習成效，並探討可能影響知識增長、心流與團體效能的遊戲元素。此研究受試者為五年級至兒科輪訓之馬偕醫學院醫學生，依授課時段分為遊戲教學組與傳統教學組。遊戲教學組於課前後各施行五題測驗，並於課後填寫心流（樂趣、控制感、專注度三構面）、團體效能及遊戲元素學習效用問卷；傳統教學組則於傳統課堂、病房與門診教學前後完成相同知識測驗。本研究旨在探討遊戲式學習應用於醫學生兒童發展課程中的成效與影響因素。首先，評估遊戲式學習相較於傳統教學方式，是否能有效提升醫學生對兒童發展相關知識之掌握程度。本研究將進一步分析不同遊戲元素對學習成效之影響，學習成效涵蓋知識增長、心流狀態（flow state）與團體效能（collective efficacy）三個層面。進一步將探討上述三項學習成效間之相互關聯性，以理解其潛在交互影響。最後整理學生主觀認為對學習具有益處之遊戲元素。本研究納入遊戲教學組48 人、傳統教學組29 人。兩組前測成績無顯著差異（2.10 ± 1.22 vs. 2.28 ± 1.33，p = 0.56）。使用共變數分析控制前測後，遊戲教學組後測成績（3.60 ± 0.98）顯著優於傳統教學組（2.59 ± 1.09）[p < 0.001, η²=0.200]。相較於傳統教學（14%），遊戲教學組有更高比例的學生在後測取得 ≥ 2 分的進步（46 %）。研究中進一步使用逐步多元迴歸來分析學生在學習過程中，對於各個遊戲元素重要性的看法。以知識增長為依變項：「團隊合作」為負向預測，「公平」為正向預測。若以心流—樂趣為依變項，結果顯示「明確遊戲目標」與「規則簡單明確」為正向預測；「失敗壓力低」為負向預測。以心流—控制為依變項時，遊戲元素中的「計分競爭」為正向預測。若以心流—專注為依變項，則發現遊戲元素中的「具挑戰性」為正向預測。而以團體效能為依變項，研究發現「逐漸增加難度」為正向預測。進一步分析三項學習成效的相互關係，僅發現團體效能與心流—控制呈中度正相關。學生認為最具學習助益的遊戲元素依序為：快速回饋、明確遊戲目標、桌遊為主的玩法、團隊合作及規則簡單明確。本研究對醫學教育的貢獻：(1)遊戲式學習可顯著提升醫學生在「兒童發展」的知識表現，優於傳統課堂教學。(2) 「明確遊戲目標」與「規則簡單明確」是促進心流的關鍵元素，也是學生認為對學習有助益的元素。「團體合作」對高知識進步者可能感受較差，提醒教師在規劃遊戲式學習時須取得平衡。（3）本研究也提供初步量性研究實證，後續可透過質性方法深究學習行為與遊戲元素的交互作用。; Mastery of child development and prompt recognition of developmental delay are competencies stipulated by the Council on Medical Student Education in Pediatrics (USA) and the Royal College of Paediatrics and Child Health (UK). In Taiwan, learning child development is also considered essential across various stages of medical training, from undergraduate to postgraduate and pediatric training. Because medical students in Taiwan typically rely on rote memorization for this topic, we designed a board game–based learning approach to enhance learning and to explore how specific game elements influence knowledge, flow stats and collective efficacy. This study aims to investigate the effectiveness of game-based learning in a course of child development for medical students. First, the study examines whether game-based learning, compared to traditional instruction, can enhance medical students’ knowledge acquisition related to child development. Second, it analyzes the impact of various game elements on learning outcomes, including knowledge gain, flow stat, and collective efficacy. Third, it explores the interrelationships among these learning outcomes to better understand their potential interactions. Finally, it identifies which game elements are perceived as most beneficial to learning, providing insights for future design and refinement of the curriculum. Fifth-year medical students on their pediatrics rotation were allocated by teaching schedule to a Game-Based Group (GBG, n = 48) or a Traditional Teaching Group (TTG, n = 29). Both groups completed a five-item pre-test and post-test on child development. After the intervention, the GBG also filled out questionnaires assessing flow (enjoyment, sense of control, engagement), collective efficacy, and the perceived learning utility of 11 game elements. Baseline pre-test scores did not differ between groups (2.10 ± 1.22 vs 2.28 ± 1.33; p = 0.56). After adjustment, the GBG achieved significantly higher post-test scores than the TTG (3.60 ± 0.98 vs 2.59 ± 1.09; F(1,74)=18.49, p < 0.001, η² = 0.200). A ≥ 2-point improvement occurred in 46 % of GBG students versus 14 % of TTG students. Stepwise regression revealed that knowledge gain was negatively predicted by teamwork and positively by fairness. Flow—enjoyment was positively predicted by clear goals and simple rule, but negatively by freedom to fail. Flow—sense of control was positively predicted by scoring competition. Flow—engagement was positively predicted by challenging tasks. Gradually increasing difficulty was a positive predictor for collective efficacy, Analysis of the interrelationships among three learning outcomes revealed that collective efficacy correlated moderately with flow-sense of control. Students ranked the most helpful game elements as rapid feedback, clear goals, board-game designs, teamwork, and simple rules. In conclusion, we designed a board-game–based learning activity on child development for medical students and demonstrated that it significantly outperforms traditional instruction in immediate knowledge acquisition on child development. Clear goals and simple rules are key elements that enhance enjoyment, whereas teamwork is perceived as less beneficial by high- performing students. Our findings offer evidence-based guidance for designing future game-enhanced medical curricula and for further studies exploring learning behaviors.