探討高擬真情境模擬進行急重症醫病溝通及醫療疏失揭露技巧訓練之成效

Abstract

本研究旨在探討經急重症高擬真模擬訓練作為醫病溝通及醫療疏失揭露的方法，住院醫師在經歷過相同模擬訓練及標準家屬的溝通訓練，但若接受不同內容的檢討後，對於醫療溝通或是醫療疏失揭露的表現是否有不同。 本研究之方法為以台灣北部單一醫學中心過去三年共92位第一年升第二年內科住院醫師作為研究對象，採取隨機分組成實驗組及對照組，透過兩次相同的教案間不同的模擬訓練後的醫病溝通檢討做為介入。學員在加護病房的模擬環境下經歷高擬真模擬訓練及向模擬家屬揭露醫療疏失，在第一次模擬訓練之後實驗組針對其模擬訓練內容進行事後檢討並強調醫療疏失揭露技巧；對照組則是針對其模擬訓練內容進行事後檢討並未強調醫療疏失揭露技巧。此外在第一次模擬結束後，兩組學員及模擬家屬會針對表現填寫問卷評估。接著兩組進入第二次模擬訓練及向模擬家屬揭露生命末期消息。模擬結束後，一樣會針對其模擬訓練內容進行事後檢討，再次請兩組學員及模擬家屬會針對表現填寫問卷評估。針對模擬訓練時學員表現採全程錄影錄音。最後，由專家針對學員表現的錄影帶進行分析及評分。 本研究利用學員自評、標準家屬評分及專家評分的分數，進行兩組各自兩次模擬訓練的問卷分數的成對樣本t檢定、以及實驗組跟對照組間的獨立樣本t檢定。本研究顯示透過模擬訓練之後，對於實驗組學員自評來說，會顯著提高表現的有採取開放式提問及整體表現。而實驗組學員帶給標準家屬的感受來說，適切問候家屬並自我介紹並展現親切感，以及語氣、眼神、手勢、坐站姿或儀態令人感到親切、關懷，還有在適當運用開放式問句是有明顯進步。而專家面對實驗組的表現則認為學員在採取開放式提問能力方面是有進步。但是實驗組及對照組在兩者之間的第二次模擬訓練結果是無統計學差異。本研究假設的經過模擬訓練後實驗組應有較明顯的溝通技巧進步，結果並無法支持，但是對於標準家屬來說，實驗組在第二次的溝通表現的確較對照組為佳。模擬訓練或許對於醫病溝通及醫療疏失揭露技巧或有幫助，但其訓練方式如何達到最高效益仍有待進一步研究。

The aim of this study was to investigate whether the residents had experienced the same simulated training and training of standard family members as a method of medical communication and medical error disclosure. However, if the trainees after receiving different contents of the simulation debriefing, whether there is a difference in the performance of medical communication or medical malpractice. From February 2013 through July 2016, we randomly assigned 92 internal medicine residents at one medical center in north Taiwan who almost finished first year residents training to experimental group and control groups, which through the same case scenarios but two different teaching plan debriefing focus as an intervention. In the simulated intensive care environment, the trainees experienced hybrid high-fidelity simulation in critical care patient and exposed the medical error to standard family. After the first simulation, tutor debriefed about the clinical performance to both two groups of trainees but only highlighted the medical communication skills and the skill of medical error exposure to experimental group. In addition, after the first simulation, the two groups of students and standard family members filled the questionnaire for performance evaluation about communication skills. Then the two groups entered the second simulation training and exposed the end-of-life condition to the standard family members. After the end of the second simulation, tutor also debriefed about simulation training content. Again, we invited two groups of residents and standard families to fill the questionnaire for the performance evaluation about communication skills. We videotaped all sessions for analysis by experts. In this study, we calculated the scores of residents' self-evaluation, standard family members evaluation and experts’ evaluation in each questionnaire with Likert scales. We used paired t test to compare two communication scores in each trainee by three different evaluation groups, and the independent sample t-test between the experimental group and the control group. We found significantly improve the performance of the” open question” and “the overall performance” in the experimental group of residents’ self-evaluation. And the experimental group of residents to bring the feelings of the standard family, “the appropriate greetings of family members” and “introduce themselves and show intimacy”, as well as” tone, eyes, gestures, sitting or gesture is very cordial, caring”, and “in the appropriate use of open” had a clear improvement. The experts considered the performance of the experimental group that the trainees in the “open question” ability to have improvement. But there was no significant difference between the experimental group and the control group in the second simulation performance. In this study, it is suggested that the experimental group should have better communication skills but the results cannot be supported. However, for the standard families, the experimental group was better than the control group in the second simulation. Simulation for medical communication and medical error disclosure training may be useful, but how to achieve the highest level of training remains to be further studied.