2009 08 08 1 問問問問問問問問 問問問問 「」 : My Perspective on PBL 問問問 問問 問問問問問問問問問問問 2009 PBL 問問問問問問
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「問題導向學習」:我的觀點My Perspective on PBL
楊仁宏 教授中山醫學大學醫學系主任
2009 PBL 師資訓練營營
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內 容 綱 要內 容 綱 要
.壹 醫學教育的目標
.貳 PBL融入課程設計
.參 PBL與臨床核心能力
.肆 PBL 與 EBM
.伍 結語
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二十一世紀醫師必備的四種特質
• 利他主義利他主義 (altruism)(altruism)
• 知識淵博知識淵博 (knowledgeable)(knowledgeable)
• 臨床技術熟練臨床技術熟練 (skillful)(skillful)
• 負責任負責任 (dutiful)(dutiful)
醫學教育目標:美國醫學院學會( Association of American Medical College, Medical School Objectives Project, 1998 )
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1. Basic biomedical sciences
2. Basic behavioral sciences
3. Social sciences
4. General clinical skills
5. Clinical decision skills
6. Communication abilities
7. Medical ethics
WFME 2003WFME 2003
World Core Medical CurriculumWorld Core Medical Curriculum
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Six General Competencies ACGME and AAMC
1. Patient care
2. Medical knowledge
3. Practice-based learning and improvement
4. Interpersonal and communication skills
5. Professionalism
6. Systems-based practice
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中山醫學大學醫學教育現藍圖
以學生為主體的學習 (learner-centredness)1. 大班授課:知識的傳授 3. 導師制 (mentor) :言教、身教2. 小組學習 ( 含 PBL) :培養終身學習的能力 4. 典範學習 (hidden curriculum) :身教
器官 / 系統整合的模組課程 融入臨床關聯性
臨床醫學初階指導 :• 臨床小組教學• 內容:病史詢問、身體檢查、 病歷紀錄、醫病關係
臨床醫學 ( 以病人為中心的醫療 ) :落實 primary care ,完成核心課程原則 :
動手做 (hands-on experience)做中學 (practice-based learning)
• 5,6 年級實習醫學生 : clerkship• 7 年級實習醫學生 : internship (UGY)
教育內容
培養學生「做良醫之前,先學做人」• 文化素養• 生命智慧• 科學精神• 分析思辨能力• 表達溝通技巧• 終身學習的能力
策略
目標 培養具備九大核心能力,為畢業後醫學訓練與研究奠立紮實的基礎。
評量
多元評量1. MCQ 3. Mini-CEX 5. Direct observation of procedure skills2. Essay 4. OSCE 6. others: report, portfolio, 360 degree
年級 一一 二二 三三 四四 五五 六六 七七
多元化入學管道,增加面談取材
宗旨 醫學的目的在救人,醫人醫病要醫心。
整合基礎臨床的模組教學 臨床實習通識博雅教育課程
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Outcome
課程、評量
回饋
九大核心能力九大核心能力(( 知識、技能與態度知識、技能與態度 ))
• 病人照護病人照護• 基礎醫學基礎醫學• 臨床醫學臨床醫學• 實證醫學實證醫學• 溝通技巧溝通技巧• 人文素養人文素養• 醫學倫理醫學倫理• 團隊合作團隊合作 (( 醫療體醫療體
系系 ) ) • 終身學習終身學習
Competency
培養具備九大核心能力,培養具備九大核心能力,為畢業後醫學訓練為畢業後醫學訓練與研究奠立紮實的與研究奠立紮實的基礎基礎
中山醫學大學的成果導向教育Outcome-based Medical Education of CSMU
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中山醫學大學醫學課程規劃中山醫學大學醫學課程規劃
一 二 三 四 五 六 七
Pre-medPre-med
Basic-Clinical Basic-Clinical IntegrationIntegration
(organ/system based)(organ/system based)
Clinical Medicine Clinical Medicine (primary care) (primary care)
Intern Intern (UGY)(UGY)
Mini-CEXMini-CEX OSCEOSCEGOSCEGOSCE
SummativeSummativeEvaluationEvaluationFormative EvaluationFormative Evaluation
GOSCEGOSCE
PBL: medical ethics, basic and clinical vignettesPBL: medical ethics, basic and clinical vignettes
PBL Workshop PBL Workshop
Medical ServiceMedical Service
Medical curriculum (2003 09 admission~)Medical curriculum (2003 09 admission~)
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Educational Methods
LCME Curriculum Checklists
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Educational Methods
LCME Curriculum Checklists
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Bloom's Taxonomy by Level
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Teaching activities to target each domainTeaching activities to target each domain
• Cognitive-– lecture, discussion, reading, diagramming, case
studies and drills• Psychomotor-
– skills practice, scenarios, simulations, and role playing
• Affective-– modeling behaviors you expect the students to
emulate (tolerance, punctuality, respect, kindness, honesty and integrity), role playing situations
– involving affective domain content, sensitivity training and awareness courses
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Lecture(5%)
Reading(10%)
Audiovisual (20%)
Demonstration (30%)
Discussion Group (50%)
Practice By Doing (75%)
Teach Others / Immediate Use of Learning (90%)
Bethel, Maine: National Training Laboratories (1960s)
Average RetentionRate after 24 hours
PBLPBL
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問題導向學習 問題導向學習 (PBL) (PBL) 過程過程
個案 小組腦力激盪,找出問題找出問題
列舉不明問題,設定學習目標
小組回報與討論
個案總結與分析 (Wrap up)
利用資源 解決問題 回家做功課
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中山醫大 中山醫大 PBL PBL 的步驟的步驟1.1. ‘‘Elect’ chair and scribe, and presentation of the scenario Elect’ chair and scribe, and presentation of the scenario
2.2. Clarify terms and unknowns Clarify terms and unknowns
3.3. Discuss what is known/ preliminary ideas Discuss what is known/ preliminary ideas (Brainstorming)(Brainstorming)
4.4. Determine objectives/ learning issues Determine objectives/ learning issues
5.5. Self-directed study Self-directed study
6.6. Share new information/ knowledge and (Re) formulate Share new information/ knowledge and (Re) formulate
7.7. Reflect, feedback and evaluation.Reflect, feedback and evaluation.Modified from the Maastricht “seven jump” process
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PBL tutorialPBL tutorial
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小小組組學習學習 (PBL)(PBL) 學習過程的評估項學習過程的評估項目目
(Formative evaluation)(Formative evaluation)
• 對小組對小組功能進行評估-提昇小組討論氣氛及效率• 對自我對自我進行評估-提昇自我的表達、溝通、學習態度等
能力• 對同儕對同儕進行評估-幫助同儕改進缺點及學習同儕的優點• 對老師對老師進行評估-提供小班導師帶班及改進的參考• 老師對學生老師對學生進行評估-提供學生具體建議,使其發揮優
點、改正缺點。
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PBL 學生評教師
OK
OK
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PBL PBL 教師評學生教師評學生
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學生自評與互評學生自評與互評
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PBL 的優缺點優點 Small group Self-directed Constructive process Collaboration Communication Evidence-based
medicine Problem-solving skills Life-long learning Feedback
缺點老師角色的改變 ( 老師的接受度 )
學生角色的改變 ( 對學習動機差的同學
---- 後果 ?)
人力、資源的需求
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醫五同學分享醫五同學分享 PBLPBL 心得心得::FeedbackFeedback
2007 03 072009 08 08
------- PBL 不是壞事,問題在於台灣學生普遍沒有『自己唸書』的習慣,不唸書的人,讓他學會了唸書方法又能怎樣 ???
學生的 學生的 FeedbackFeedback
~ 無名氏:一則網路發表的 PBL 文章醫二甲 王淳理 2006 ~
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『白駝山一派內功上手甚易,進展快速,不比全真派內功在求根基紮實。在初練的十年之中,白駝山的弟子功力高出甚多,直到十年之後,全真派弟子才慢慢趕將上來。 』但是 --- 萬一雙方都偷懶不練呢?那全真派弟子 ???
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CMAJ 2008;178(1):34-41
1.1. OverallOverall
2.2. Technical Technical -- 77
3.3. Social Social - - 88
4.4. Cognitive Cognitive -- 1212
5.5. Managerial Managerial -- 33
6.6. Research Research -- 22
7.7. Teaching Teaching -- 22
8.8. Knowledge Knowledge -- 22
8 dimensions8 dimensions
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8 dimensions8 dimensions
• OverallOverall
• Technical Technical -- 77• Social Social - - 88
• Cognitive Cognitive -- 1212
• Managerial Managerial -- 33
• Research Research -- 22
• Teaching Teaching -- 22
• Knowledge Knowledge -- 22
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4 competencies in support of PBL4 competencies in support of PBL (both self- and observed assessments) (both self- and observed assessments)
• Coping with uncertainty (s)
• Appreciation of legal and ethical aspects of healthcare (s)
• Communication skills (m/s)
• Self-directed continuing learning (m)
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PBL during medical school has positive effects on physician competency after graduation, mainly in social and cognitive dimensions.
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問題導向學習與臨床教育問題導向學習與臨床教育PBL and Clinical PBL and Clinical
EducationEducation
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PBL + EBMPBL + EBM
1. To select a clinical scenario from a real patient.
2. To formulate a problem list (PBL-EBM 臨床問題分析單 ).
3. To answer a specific question with EBM
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Clinical Scenario - 1
•一對剛結婚的年輕夫婦步入診所,詢問懷孕前應該注意的事情,醫師建議進行婚前健康檢查。
•檢查報告完成後,發現先生為 B 型肝炎健康帶原者,太太有甲狀腺機能亢進,他們非常恐慌,問了一連串的問題:
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Clinical Scenario - 2•需要治療嗎 ? •治療期間可不可以懷孕?•治療對母親或胎兒會有什麼影響 ?•懷孕期間需要繼續吃藥嗎?•如需治療,藥物會不會導致胎兒畸形?•不治療會怎樣 ? ---• ------•由於問題很多,您與病人約好下週諮詢,也好利用時間好好找資料回答上列問題。
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PICOPICO type: Therapy
Patient: A woman with hyperthyroidism and she wants to have a baby
Intervention:
Propylthiouracil
Comparator:
Methimazole
Outcome: The fetal abnormality (development defects, teratogenecity, fetal hypothyroidism…) and mother risk (uncontrolled hyperthyroidism, abortion…)
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PBL--EBM臨床問題分析單日 期 : 學 號 : 學 員 :
單 位 : 職 稱 :
問題敘述 : A woman with hyperthyroidism and she wants to have a baby
關鍵字 : Propylthiouracil / hyperthyroidism/ methimazole/ fetal abnormality
查詢之資料庫 : Medline、 Cochrane、 ACP、 BMJ、 DARE 、 other database
文獻等級、主要內容 : Level 1:RCT / Level 2:cohort study / Level 3:case control / Level 4:case series / Level 5: expert opinion
與臨床狀況之比較分析 :
實證醫學中心回覆 :
可諮詢之人員或單位 : 各科、室實證種子講師,實證醫學中心
中山中山
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Outlines: 5AOutlines: 5AConverting the need for information into an answerable question.
Searching the best evidence with which to answer that question. Text in
hereAcquire
Text in hereAsk
Critically appraising the evidence for its validity, impact, and applicability.Text in
hereAppraisal
Integrating the evidence with our clinical expertise and patients’ unique biology, values and circumstances.
Text in here
Apply
Evaluating our effectiveness and efficiency in executing steps 1-4 and seeking ways to improve them both for next time.
Text in hereAudit
Step1:
Step2:
Step3:
Step4:
Step5:
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Cochrane LibraryStrategy
Advanced search Key words hyperthyroidism and pregnancy* Cochrane revies (5); Clinical trials (11) hit 2
Results
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BMJ Clinical Evidence
Key words hyperthyroidism and pregnancy 1 篇 journal
Results
Strategy
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SUMMARYSUMMARY
• Bottom Line: Antithyroid drug is recommended during pregnancy
• Propylthiouracil should still be considered as the first-line agent in the treatment of hyperthyroidism disease during pregnancy
• 證據等級: IIa (systemic reviews of cohort studies)
• 建議等級: Grade B-C ( extrapolation from level 2 or 3 studies )
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can offer as an powerful educational tool
for clinical reasoning and training.
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實証醫學權威醫學
大聲公醫學雄辯醫學天命醫學傲慢醫學
「在你穿上白袍之前 : 醫生媽媽給兒子的十封信」 天下 2009
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Evidence-Based Clinical DecisionsEvidence-Based Clinical Decisions
EvidenceEvidence
PatientClinical environment
Clinical expertise & Clinical expertise & experienceexperience
Modified from R Brain Haynes et al.: Evid. Based Med. 2002;7;36-38.
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Thank you Thank you
for your for your attention !attention !
敬請指教敬請指教 !!
2009 08 08