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1 一般內科教學研討會會議手冊目錄壹議程表...1 貳與會名單...3 參議題 - 如何做好一般內科教學 / 美國一般內科現況畢業後一般醫學訓練與一般醫學訓練示範中心中榮示範中心經驗分享北榮示範中心經驗分享高醫示範中心經驗分享肆附件 - Recommendations For Medical Education In Taiwan 美國內科住院醫師訓練 Some Thoughts About The Teaching Of General Internal Medicine In Taiwan 對台灣一般內科醫學教學的感想與建議...133

3 一般內科教學研討會主題:一般內科教學日期: 2010 年 3 月 21 日 ( 星期日 ) 地點:台大醫院國際會議中心 403 室主辦單位:台灣醫學教育學會合辦單位:台大醫院內科部台大醫院一般醫學示範中心背景:台灣專科醫師制度已實施 20 多年, 且內科次專科醫師訓練亦實施多年, 因而大家對一般內科及一般醫學較不重視國內目前積極推動畢業後一般醫學訓練且本學會亦積極推動一般醫學訓練示範中心及一般醫學師培育特藉此研討會邀集美國及國內關心一般醫學教育之人士共同研商目前推動的現況和困難以及因應之道討論的範圍包括: 1. 如何做好臨床教學 ( 以一般內科為例 ) 2. 美國一般內科現況及師資培育 3. 國內一般內科現況 4. 國內一般醫學示範中心現況 5. 國內一般醫學師資培育現況時間議程主講者主持人 13:10~13:30 報到 13:30~13:35 致詞謝博生理事長 13:35~14:35 1. 如何做好一般內科教學 2. 美國一般內科現況 Weed 教授 14:35~15:00 茶點休息 15:00~15:20 畢業後一般醫學訓練與一般朱宗信秘書長李發耀醫學訓練示範中心主任 15:20~15:40 台中榮總經驗吳明儒主任 15:40~16:00 台北榮總經驗李發耀主任 16:00~16:20 高醫附醫經驗林育志醫師 16:20~16:50 共同討論 1

4 General Internal Medicine Conference Topic: Teaching at General Internal Medicine Date: March 21, (Sunday) 2010 Place: Room 403, NTUH Convention Center Host: Taiwan Association of Medical Education Participants: Physician interested on General (Internal) Medicine Backgrounds: Issues to be addressed: 1. How to do clinical teaching (General Internal Medicine as an example) 2. GIM at OSU and USA 3. GIM at Taiwan: current status and challenges Time Topic Speakers 13:10~13:30 Registration 13:30~13:35 Welcome Remarks Prof. Bor-Shen Hsieh President, TAME 13:35~14:35 1. teaching at GIM Prof. Harrison G. Weed 2. GIM at OSU and USA 14:35~15:00 Tea Break 15:00~15:20 PGY training and general (internal) medicine training center Asso. Prof. Tzong-Shinn Chu, Secretary General, TAME 15:20~15:40 GIM at VGH, Taichung Director M-J Wu 15:40~16:00 GIM at VGH, Taipei Prof. F-Y Lee 16:00~16:20 GIM at KMUH Dr. Y-C Lin 16:20~16:50 Panel discussion All Speakers 2

5 一般內科教學研討會與會名單服務單位職稱中文姓名台灣醫學教育學會秘書長朱宗信俄亥俄州州立醫學院內科教授 Harrison Weed 台中榮總一般內科主任吳明儒台北榮總一般內科主任李發耀高醫附醫一般內科醫師林育志行政院衛生署專員李玫陵三軍總醫院一般醫學科主任張維國三軍總醫院主任闕宗熙三軍總醫院三軍總醫院三軍總醫院李忠興任益民邵蘊萍台大醫院副主任朱宗信台大醫院臨床助理教授高芷華台北市立萬芳醫院內科部副主任蘇裕謀台北市立萬芳醫院一般內科劉偉翰台北市立萬芳醫院一般內科蔡育霖台北市立萬芳醫院一般內科洪文道台北榮民總醫院主治醫師林春吉台北榮民總醫院主治醫師李文興台北榮民總醫院主治醫師黃加璋馬偕紀念醫院主任林榮祿馬偕紀念醫院主治醫師林承志亞東紀念醫院外科暨教學部主任陳芸亞東紀念醫院林姵君亞東紀念醫院主治醫師邱奕華亞東紀念醫院亞東紀念醫院國防醫學院國防醫學院國防醫學院李宗熙徐世平侯宗昀許金旺何志聰新光吳火獅紀念醫院腎臟科主任林秉熙新光吳火獅紀念醫院研究助理邱郁芬新光吳火獅紀念醫院教學研究部部主任駱惠銘新光吳火獅紀念醫院主治醫師江俊松新光吳火獅紀念醫院主治醫師方昱偉新光吳火獅紀念醫院主治醫師黃建賢林口長庚醫院教學部研究助理鄭小圓林口長庚醫院ㄧ般內科主治醫師蒲秀瑾林口長庚醫院ㄧ般內科科主任劉茂森中山醫學大學附設醫院主治醫師林俊哲 3

6 一般內科教學研討會與會名單服務單位職稱中文姓名中山醫學大學附設醫院主治醫師楊宜瑱中山醫學大學附設醫院專任助理葉妍蓁中山醫學大學附設醫院專任助理陳雅菁中山醫學大學附設醫院主治醫師劉旭崇中山醫學大學附設醫院主治醫師楊凱介台中榮總示範病房主任宋育民台中榮總主治醫師陳信華台中榮總主治醫師曾慧恩台中榮總主治醫師劉伯瑜中國醫藥大學附設醫院示範中心主治醫師葉宏傑財團法人彰化基督教醫院示範中心主持人沈銘鏡財團法人彰化基督教醫院示範中心主治醫師謝堯棚財團法人彰化基督教醫院內科部部長張家築財團法人彰化基督教醫院一般內科主任林懷正奇美醫院葉子洪奇美醫院一般內科黃信凱奇美醫院醫師王志中成大醫院一般內科主任鄭修琦成大醫院內科部部主任蔡良敏成大醫院主治醫師林威宏成大醫院助理邱鈺晴高雄長庚紀念醫院科主任李志雄高雄長庚紀念醫院內科部部主任劉建衛高雄長庚紀念醫院主治醫師陳志弘高雄長庚紀念醫院主治醫師陳勅因高雄長庚紀念醫院醫師呂致欽高雄長庚紀念醫院總醫師邱千華高雄長庚紀念醫院小兒科主治醫師刁茂盟高雄榮民總醫院一般內科主任呂志成高雄榮民總醫院一般內科主治醫師王立峰高雄榮民總醫院內科部部主任鍾孝民高雄醫學大學附設醫院一般內科蔡哲嘉國軍左營總醫院腎臟科主治醫師黃文德佛教慈濟綜合醫院醫師林彥光佛教慈濟綜合醫院一般醫學內科醫師許瑞云 4

7 如何做好一般內科教學美國一般內科現況 Prof. Harrison Weed

9 PRESENT ACADEMIC RANK AND POSITIONS CURRICULUM VITAE Harrison Goodale Weed, M.D., M.S., F.A.C.P. Suite 2400 Morehouse Pavilion 2050 Kenny Road Columbus OH , fax Professor of Clinical Medicine Ohio State University College of Medicine, Columbus OH Professor, Category M Ohio State University College of Dentistry, Columbus OH Chairperson, Ohio State University Medical Center Committees Pharmacy and Therapeutics Executive Medication Safety Computer Applications Guidance Laboratory and Clinical Testing Utilization EDUCATION February 1980: B.S., Life Sciences Massachusetts Institute of Technology, Cambridge MA BOARD CERTIFICATION MEDICAL LICENSURE September July 1980, Graduate Study, Molecular Biology University of California at San Diego, La Jolla CA September 1982: M.S., Biology Massachusetts Institute of Technology, Cambridge MA September August 1983, Graduate Study, Epidemiology Harvard University School of Public Health, Boston MA May 1987: M.D. Boston University School of Medicine, Boston MA June June 1990, Internship and Residency, Internal Medicine Boston City Hospital, Boston MA July June 1993, Fellowship, Infectious Diseases Ohio State University College of Medicine, Columbus OH 1991, 2001 Internal Medicine 1994, 2004 Infectious Diseases State of Ohio 5

10 Harrison G. Weed, MD HONORS AND AWARDS 1980 National Science Foundation Graduate Fellowship 1998 Selected by peers as a "Best Doctor" by the Best Doctors, Inc H. William Harris Visiting Professor of Internal Medicine, National Taiwan University College of Medicine PREVIOUS PROFESSIONAL POSITIONS AND APPOINTMENTS PROFESSIONAL SOCIETY ACTIVITIES Harvard School of Public Health, Boston, Massachusetts , Research Associate, Department of Radiation Biology The Ohio State University College of Medicine, Columbus, Ohio , Clinical Assistant Professor of Medicine , Assistant Professor of Clinical Medicine , Associate Professor of Clinical Medicine Fellow, American College of Physicians Member, Society of General Internal Medicine SELECTED PUBLICATIONS Books Cohn SL, Smetana G, Weed HG, editors: Perioperative Medicine. Just the Facts, New York, 2006, The McGraw-Hill Companies, Inc. Chapters: Weed HG. Otolaryngology, chapter 16. Weed HG. Endocarditis Prophylaxis, chapter 47. Weed HG. Prevention of Surgical Site Infection, chapter 48. Pile JC, Weed HG. Fever, chapter 50. Book Chapters (1) Weed HG, Forrest LA: Neck Infections in Cummings, Fredrickson, Harker, Krause, Richardson and Schuller, editors: Otolaryngology - Head and Neck Surgery, third and fourth editions, Philadelphia, 1998 and 2004, Mosby-Year Books, Inc. (2) Weed HG, Chapters in Mercado and Smetana, editors: Medical Consultation Pearls, Philadelphia 2002, Hanley & Belfus, Inc. A 62 year-old man with hereditary angioneurotic edema anticipating mastoidectomy. A 19 year-old woman with cyanotic heart disease anticipating wisdom teeth extraction. A 68 year-old woman with fatigue anticipating cholecystectomy. A 32 year-old woman with renal transplant anticipating hysterectomy. A 66 year-old man with arm deep vein thrombosis after head and neck cancer surgery. A 79 year-old woman with rheumatoid arthritis and postoperative respiratory failure. A 29 year-old man with sickle cell anemia anticipating inguinal herniorraphy. (3) Cards in Rose BD, editor UpToDate in primary care medicine, electronic medical textbook and subsequent versions. Wellesley: UpToDate a. Weed HG, Baddour LM: Postoperative Fever b. Manzullo EF, Hwang JP, Weed HG: Perioperative Issues in Patients with Cancer (4) Chapters in Perioperative Medicine, Medical Clinics of North America 2003, Cohn SL, editor, 87. a. Weed HG: Antimicrobial Prophylaxis in the Surgical Patient, pages b. Manzullo EF, Weed HG: Perioperative Issues in Patients with Cancer, pages (5) Chapters in Yeung J, Escalante C, Gagel R, editors: Medical Care of Cancer Patients, 2008, BC Decker, Inc. 6

11 Harrison G. Weed, MD a. Malone S, Weed HG. Preoperative Considerations in the Cancer Patient Undergoing Surgery, chapter 77, page 681. b. Malone S, Weed HG. Perioperative Nutritional Issues, chapter 78, pages c. Newton HB, Weed HG. Perioperative Neurologic Issues, chapter 79, pages d. Bellamy KY, Weed HG. Psychosocial Issues: The Importance of Social Support, chapter 84. pages Peer Reviewed Journal Articles (selected) (1) Weed HG. Non-venomous snakebite in Massachusetts: Prophylactic antibiotics are unnecessary. Ann Emerg Med 1993;22: (2) Pelczar BT, Weed HG, Schuller DE, Young DC and Reilley TE. Identifying high risk patients prior to head and neck oncologic surgery. Arch Otolaryngol Head Neck Surg 1993;119: (3) Weed HG, Lutman CV, Young DC, Schuller DE. Preoperative identification of patients at risk for delirium after major head and neck cancer surgery. Laryngoscope 1995;105: (4) Wasielewski RC, Weed HG, Prezioso C, Nicholson C, Puri RD. Patient comorbidity: relationship to outcomes of total knee arthroplasty. Clin Orthop Relat Res 1998;356: (5) Medow M, Weed HG, Schuller DE. Simple predictors of survival in head and neck squamous cell carcinoma. Arch Otolaryngol Head Neck Surg 2002;128: (6) Askarian M, Moravveji AR, Hossein M, Namazi S, Weed HG. Adherence to American Society of Health-system Pharmacists surgical antibiotic prophylaxis guidelines in Shiraz, Iran. Infect Control Hosp Epidemiol 2006;27: (7) Weed HG, Askarian M. Infection control dogma among nurses in Iran. Infect Control Hosp Epidemiol 2007;28: (8) [Weed HG], Lahsaeizadeh S, Jafari H, Askarian M. Healthcare-associated infection in Shiraz, Iran J Hosp Infect 2008;69(3): (9) Chu TS, Weed HG, Wu CC, Hsu HY, Lin JT, Hsieh BS. A program of accelerated medical education in Taiwan. Medical Teacher 2009;31:e74-e78 Letters/Case Reports (1) Weed HG. A case of spontaneous combustion. Ann Emerg Med 1991;20:219. (2) Weed HG. Mycobacterium ulcerans osteomyelitis following a snakebite. N Engl J Med 1993;329:582. (3) Weed HG. Identifying high-risk surgical patients by poor self-reported exercise tolerance. Arch Int Med 2000;160:1539. (4) Weed HG. Accuracy of the Mayo Patient/Family History Questionnaire. Mayo Clin Proc 2005;80:1394. (5) Weed HG. Prophylactic coronary artery revascularization before elective vascular surgery did not improve long-term survival (letter) ACP Journal Club 2005 Nov-Dec;143:A12. (6) Weed HG. Preoperative urine testing (letter) Cortlandt Forum. March Reviews (1) Weed HG. Pulmonary "capillary" wedge pressure not the pressure in the pulmonary capillaries. Chest 1991;100: (2) Weed HG. Educating medical students in primary care. J Med Education 2000;4(3): (3) Weed HG. Some thoughts about the teaching of general internal medicine in Taiwan. J Med Education 2006;10(2): (editor requested) (4) Weed HG. Commentary on a Review: enhanced oral hygiene prevents respiratory infection in elderly people in hospitals and nursing homes. Evidence-Based Medicine 2009;14(3):80. (5) Chu, TS, Weed HG, Yang PC. Recommendations for Medical Education in Taiwan. J Formos Med Assoc 2009;108(11):

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13 General Internal Medicine Education at OSU and in the USA Harrison G. Weed, MD, MS, FACP Professor of Clinical Internal Medicine Division of General Internal Medicine The Ohio State University College of Medicine Outline 1. A brief history of General Internal Medicine education in the United States. 2. The current approach to General Internal Medicine education at the Ohio State University College of Medicine. 9

14 1910 The Flexner Report A comprehensive study of undergraduate medical education in the U.S. and Canada written by Abraham Flexner, a professional educator who visited all 155 U.S. and Canadian medical schools The Flexner Report Conclusions Admission to a medical school should require 2 years of college or university study in physics, chemistry, and biology. Medical education should require 2 years of Anatomy and Physiology 2 years of clinical work in a Teaching Hospital. 10

15 1910 The Flexner Report Consequences From 1910 to 1935, 89 U.S medical schools merged or were closed. The number of U.S. doctors decreased from 173/100,000 to 120/100,000. Graduate Medical Education What was happening to graduate medical education at this time? 11

16 1900 In 1900 most doctors began practice after graduating from medical school. Some doctors who wanted additional training would obtain an internship at a teaching hospital, that might become a residency position and then a teaching position Medical Specialty Boards The idea of creating a board to specify qualifications, to supervise examinations and to issue credentials for special types of medical practice was first proposed in

17 1933 In 1933 a conference of public and private, federal and state, medical and hospital organizations created what ultimately became the American Board of Medical Specialties (ABMS), a non-profit, physician-led organization for 24 of the 26 approved medical specialty boards in the U.S. ABMS The ABMS works with Member Boards to set educational and professional standards for the certification of physician specialists. The Board also collaborates with other medical organizations and agencies to set standards for graduate medical education and accreditation of residency training programs. The Member Boards certify specialists in 145 specialties and subspecialties. 13

18 Internal Medicine By the 1930s Internal Medicine, the scientific care of patients with complex problems of the internal organs, had become a specialty, and in 1936 the American Board of Internal Medicine (ABIM) was formed. 1940s In the 1940s competition for internship positions meant that medical students who wanted to obtain additional training after graduation were having to commit to a training program by the 3 rd year of medical school. 14

19 1952 In 1952 the internship/residency matching program was created to allow more time for students to develop before they committed to a training program, and to allow time for both students and programs to choose each other. 1950s Matching actually started in individual cities. There were initially different matching programs for Boston, New York, and Philadelphia. 15

20 Recap: the Consequences of the Flexner Report From 1910 to 1935, 89 U.S medical schools merged or were closed. The number of U.S. doctors decreased from 173/100,000 to 120/100, s Although the number of doctors/person had risen since the 1930s, in the 1950s the number of doctors in the U.S. was still considered insufficient for current and future needs. The Surgeon General of the United States commissioned a report on medical education. 16

21 1959 The Bane Report In 1959 the Surgeon General's Consultant Group on Medical Education report was published. It became known as the Bane Report. Between 1965 and 1980, the number of medical schools increased from 88 to 126, and the annual number of graduates grew from 7,409 to 15, Medicare In 1965 Medicare was signed into law. It is a program of medical insurance provided by the U.S. government. It covers people over the age of 65 and people with disabilities. It is paid for by a special tax on wages. 17

22 Medicare also pays for graduate medical education. Because of the concern for an insufficient number of doctors in the U.S. when Medicare was created, Medicare includes funding to pay for graduate medical education. Medicare and Graduate Medical Education (GME) Medicare currently pays $80,000/resident in accredited graduate medical training (residency) programs. In 1986 the Council for Graduate Medical Education (CGME) was created by the U.S. government to address graduate medical education and the supply of physicians. 18

23 Accreditation The GCME created the Accreditation Council for Graduate Medical Education (ACGME) which is responsible for accrediting graduate medical training programs in the U.S., and therefore identifying which programs qualify for Medicare funding. The Accreditation Council for Graduate Medical Education (ACGME) Because the ACGME determines whether a residency program receives Federal Medicare funding, it controls the content and structure of programs. For example, in 2003 the ACGME promulgated work hour rules limiting residents to an 80-hour work week. 19

24 Medical Licensing To practice medicine in the United States a doctor must be licensed. Medical practice licenses are granted by each of the 50 individual states within the United States. All states require at least 1 year of postgraduate medical training for licensure and many require 2 years for U.S. medical graduates and 3 years for foreign medical graduates. Summary Graduate medical education in the U.S. is shaped by several factors including: Medicare funding ACGME accreditation requirements Specialty board requirements State licensing requirements 20

25 Competing Interests Note that there may be competing interests. While both the government and the specialty boards want to maintain quality, the state may be interested in increasing physician supply to enhance availability of care and reduce cost of services; whereas the specialty boards may prefer not to increase physician supply in order to enhance practice opportunities. Questions? 21

26 General Internal Medicine Education at the Ohio State University Because the funding of graduate medical education flows from Medicare through the hospital, the residency program is a collaborative effort between the hospital and the academic department. 22

27 Hospital / Department Collaboration For example, the Hospital funded the creation of a Simulation Center with: IV line placement simulators, central line placement simulators, endoscopy simulators, and anesthesia training mannequins, as well as standardized patient interviewing rooms. Hospital / Department Collaboration The Hospital also gives half of the Medicare Residency money directly to the Department to fund the residency training program. This funding is critical support for the teaching activities of the residency training program. 23

28 Hospital / Department Collaboration The Department, through the College of Medicine also supports residency training. For example, the College of Medicine s promotion criteria include consideration of activities such as directing residency programs. The Educational Innovations Project In 2005 OSU Internal Medicine passed the ACGME residency review and became one of 17 Internal Medicine residency programs in the U.S. to earn the opportunity to develop new residency education programs. 24

29 Principles of the OSU GIM Innovative Training Program Quality Improvement Demonstrable Competency Effective Teamwork Principles of the OSU GIM Innovative Training Program Quality Improvement Residents will analyze data and initiate strategies to improve both their own performance and the performance of their colleagues and the institution. 25

30 Principles of the OSU GIM Innovative Training Program Demonstrable Competency Residents will demonstrate competency through measurable outcomes. Principles of the OSU GIM Innovative Training Program Effective Teamwork Residents will demonstrate effective leadership and monitoring of the multidisciplinary healthcare teams on which they serve. 26

31 Principles of the OSU GIM Innovative Training Program Quality Improvement Demonstrable Competency Effective Teamwork How are residents assessed? Residents are assessed with a web-based based questionnaire completed by attending physicians at the end of clinical rotations. The questionnaire includes rating the resident s s competency in specific clinical and teamwork skills and free text areas for attending physicians comments. 27

32 In addition, residents are assessed by: patient satisfaction surveys other members of the healthcare team, e.g. nurses their adherence to infection control and quality activities such as: hand washing use of a timeout before procedures barrier precautions to avoid disease transmission. Pathways There are 4 different pathways for Internal Medicine (IM) residency training at OSU. Categorical Internal Medicine/Pediatrics Research Track Preliminary Year 28

33 Categorical IM Training (months) YEAR 1 YEAR 2 YEAR 3 ICU Inpatient Outpatient Elective E.D Outpatient Internal Medicine Note that more than 1/3 of training is in the outpatient setting. All Categorical IM residents have an outpatient continuity clinic. 29

34 Outpatient Continuity Clinic The clinics are organized into practices of 3 residents who share the same patient panel. One of the 3 resident is always on an outpatient rotation, seeing patients from the panel in clinic, and managing patient calls and paperwork. Outpatient Electronic Medical Record The Hospital purchased and supports a full electronic medical record (EMR). The EMR includes prescribing, laboratory and test ordering, and a patient portal for patients to access their own records and to communicate securely with their doctors. 30

35 Outpatient Continuity Clinic Residents are expected to use the EMR for all patient care activities including communication with other caregivers. They are overseen by attending physicians who are having to learn new ways of teaching while using the EMR. Additional outpatient Internal Medicine training opportunities include: a Veterans Clinic local nursing homes Columbus City Health Clinics Community Medicine Programs in rural Ohio towns 31

36 Career Development Note also that there is 1 month of Elective in the Internship year. During this month the intern performs a scholarly project either in research, medical education, or clinical quality improvement. Pathways There are 4 different pathways for Internal Medicine (IM) residency training at OSU. Categorical Internal Medicine/Pediatrics Research Track Preliminary Year 32

37 Internal Medicine/Pediatrics 4-year program Both inpatient and outpatient, Internal Medicine and Pediatrics training Qualifying residents to sit for both boards 4 Pathways Categorical Internal Medicine/Pediatrics Research Track Preliminary Year 33

38 Research / Fellowship Track 6 to 7-year 7 program 2 years of internship and residency 3 to 4 years of research training in subspecialty along with weekly outpatient clinic 1 year of clinical fellowship in subspecialty Research In addition to the formal Research track, several residents each year use their elective time to perform and publish research. 34

39 4 Pathways Categorical Internal Medicine/Pediatrics Research Track Preliminary Year Preliminary Year The preliminary year pathway is for first year residents / interns who will go on for training in Anesthesia, Dermatology, Ophthalmology, or Neurology. The Neurology pathway is coordinated with the OSU Department of Neurology. 35

40 Preliminary Year MONTHS INPATIENT MICU NIGHT FLOAT EMERGENCY VA OUTPATIENT ELECTIVE Preliminary Year Note that the preliminary year does not include an outpatient Internal Medicine continuity clinic, but it does include opportunities for training in other outpatient settings. 36

41 Electronic Resources Each clinical rotation includes a web based curriculum with learning objectives, full text article links, core clinical images, and links to self assessment sites. Clinical Teaching An important part of residency education is teaching residents to teach. In the transition from intern to resident all residents participate in a one-day workshop on teaching. 37

42 Residents Teaching Workshop Didactic presentations on leadership: agenda setting, time management, negotiation skills, conflict resolution skills Didactic presentations on teaching: establishing a good learning climate, effective questioning skills, observing and assessing procedural skills Simulation based hands-on sessions Code Blue Leadership Training using a high fidelity METI Simulator Standardized Learners to provide realistic opportunities to practice teaching skills Standardized Nurses and Faculty to provide realistic practice in conflict resolution and negotiation skills. Monthly Faculty Development Conference Every month there is a different skills-based conference to develop the teaching skills of faculty. All residents are encouraged and provided time to attend these conferences which often last ½ day. 38

43 Recent topics at the Monthly Faculty Development Conference Writing Questions for Tests and Learning Effective Teaching when Time is Tight Using Technology to Teach Physical Diagnosis What is Validity? Feedback on the Fly Why Johnnie Can t t Learn Summary With support from the Hospital and the University OSU has developed an innovative program of graduate Internal Medicine education that guides residents to develop the necessary skills to practice now and in the future. 39

44 Thank you 40

45 畢業後一般醫學訓練與一般醫學訓練示範中心朱宗信秘書長

47 PRESENT ACADEMIC RANK AND POSITIONS EDUCATION BOARD CERTIFICATION MEDICAL LICENSURE HONORS AND AWARDS CURRICULUM VITAE Tzong Shinn, Chu, M.D. No.7, Chung-Shan S. Rd., Taipei 100, Taiwan #65403, fax Associate Professor of Medicine Department of Primary Care Medicine National Taiwan University College of Medicine Vice Chairman, Department of Internal Medicine, National Taiwan University Hospital September June 1982: M.D. National Taiwan University College of Medicine, Taipei, Taiwan September 1989 January 1997: Ph.D. Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei, Taiwan Internal Medicine Nephrology Taiwan, # Second Grade Service Award, Executive Yuan Academic Research Award, National Taiwan University Academic Research Award, National Taiwan University Recipient of the Award for Excellent Innovative Teaching Material. National Taiwan University Hospital Ten Years Senior Excellent Teacher Award, National Taiwan University PREVIOUS PROFESSIONAL POSITIONS AND APPOINTMENTS The University of Texas Southwestern Medical Center at Dallas Research fellow of Nephrology National Taiwan University Hospital, Taipei, Taiwan Resident, Department of Internal Medicine Visiting staff, Nephrology Division, Department of Internal Medicine Assistant Professor of Medicine The National Taiwan University College of Medicine, Taipei Taiwan , Assistant Professor of Medicine, Department of Primary Care Medicine 41

48 TS CHU, M.D., Ph.D PROFESSIONAL SOCIETY ACTIVITIES SELECTED PUBLICATIONS Books Secretary General, Taiwan Association of Medical Education Editor, Journal of Acta Nephrologica Executive editor, Journal of Medical Education Reviewer, Journal of the Formosan Medical Association Member, the Education Committee of Taiwan Society of Nephrology Executive secretary, the Education Committee of Taiwan Society of Internal Medicine Member, Executive Board, Taiwan Hypertension Society Member, Hospital Accreditation, Department of Health Member, International Society of Nephrology Member, American Society of Nephrology Member, Society of General Internal Medicine Member, Association for Medical Education in Europe Chu TS: Health Profession Education, Taiwan Joint Commission of Hospital Accreditation, Taipei, pp (in Chinese) Book Chapters 1. Chu TS: Kidney and Health, In Lin JT ed. General Medicine and Health Promotion. Professor Wang TH Foundation, Taipei: 2004, pp (in Chinese) 2. Chu TS: Adequacy of Dialysis. In Chang SC ed. Evidence Based Medicine Manual. Taiwan Joint Commission of Hospital Accreditation. Taipei, 2004, pp (in Chinese) 3. Chu TS: Renal Diseases. In Yang RS ed. Clinical Nutrition. China Times News Publisher. Taipei, 2005, pp (in Chinese) 4. Chu TS: Acid-Base Disturbances. In Chang TC ed. Internal Medicine 5 th ed. Orange Well, Taipei, 2007, pp (in Chinese) 5. Chu TS: Evolution of Postgraduate Medical Education in Taiwan, In Chu TS ed. General Competencies of Postgraduate Medical Education. Taiwan Association of Medical Education, Taipei, 2009, pp (in Chinese) Peer Reviewed Journal Articles 1. Yang SY, Huang JW, Shih KY, Hsu SP, Chu PL, Chu Tzong Shinn, Wu KD: (2005/1) Factors associated with increased plasma homocysteine in patients using an amino acid peritoneal dialysis fluid. Nephrol Dial Transpl 2005; 20: Chu TS, Wu MS, Hsieh BS: (2005/5) Vasodilator agents inhibit opossum kidney proximal tubular cell growth. J Formos Med Assoc 2005; 104: (Corresponding author) 3. Huang JW, Chen KY, Tsai HB, Wu VC, Yang YF, Wu MS, Chu TS, Wu KD, and the SARS Research Group NTUH: (2005/12) Acute renal failure in patients with severe acute respiratory syndrome. J Formos Med Assoc 2005; 104: Fang CC, Yen CJ, Chen YM, Chu TS, Lin MT, Yang JY, Tsai TJ: (2006/5) Diltiazem suppresses collagen synthesis and IL-1beta-induced TGF-beta1 production on human peritoneal mesothelial cells. Nephrol Dial Transpl 2006; 21(5): Chu PL, Wei YF, Huang JW, Chen SI, Chu TS, Wu KD: (2006/8) Clinical characteristics of patients with segmental renal infarction. Nephrology 2006; 11(4): (Corresponding author) 6. Tsai IC, Huang JW, Chu TS, Wu KD, Tsai TJ. (2007/2) Factors associated with metabolic acidosis in patients receiving parenteral nutrition. Nephrology 2007;12(1):3-7. (Corresponding author) 7. Chu TS, Wu MS, Wu KD, Hsieh BS. (2007/4) Endothelin-1 activates MAPKs and modulates cell cycle 42

49 TS CHU, M.D., Ph.D proteins in OKP cells. J Formos Med Assoc 2007;106(4): (Corresponding author) 8. Chang HW, Chu TS, Huang HY, Chueh SC, Wu VC, Chen YM, Hsieh BS, Wu KD.(2007/5) Downregulation of D2 dopamine receptor and increased protein kinase Cmu phosphorylation in aldosteroneproducing adenoma play roles in aldosterone overproduction. J Clin Endocrinol Metab. 2007;92(5): Chang HW, Wu VC, Huang CY, Huang HY, Chen YM, Chu TS, Wu KD, Hsieh BS. (2008/3) D4 dopamine receptor enhances angiotensin II-stimulated aldosterone secretion through PKC-varepsilon and calcium signaling. Am J Physiol Endocrinol Metab. 2008;294(3):E622-E Chen HY, Kao TW, Huang JW, Chu TS, Wu KD. (2008/3) Correlation of metabolic syndrome with residual renal function, solute transport rate and peritoneal solute clearance in chronic peritoneal dialysis patients. Blood Purificat 2008;26(2): Li WY, Chu TS, Huang JW, Wu MS, Wu KD. (2008/11) Randomized study of darbepoetin alfa and recombinant human erythropoietin for treatment of renal anemia in chronic renal failure patients receiving peritoneal dialysis. J Formos Med Assoc. 2008;107(11): (Corresponding author) 12. Tsai CW, Lin YF, Wu VC, Chu TS, Chen YM, Hu FC, Wu KD, Ko WJ. the NSARF Study Group. (2008/12) SAPS 3 at dialysis commencement is predictive of hospital mortality in patients supported by extracorporeal membrane oxygenation and acute dialysis. Eur J Cardiothorac Surg. 2008;34 (6): Lin YF, Ko WJ, Wu VC, Chen YS, Chen YM, Hu FC, Shiao CC, Wu MS, Chen YW, Li WY, Huang TM, Wu KD, Chu TS. (2008/12) A modified sequential organ failure assessment score to predict hospital mortality of postoperative acute renal failure patients requiring renal replacement therapy. Blood Purificat 2008;26(6): (Corresponding author) 14. Chu TS, Chang SC, Hsieh BS: (2008/12) The learning of 7th year medical students at internal medicineevaluation by logbooks. Ann Acad Med Singap 2008:37(12): (Corresponding author) 15. Lin YF, Huang JW, Wu MS, Chu TS, Lin SL, Chen YM, Tsai TJ, Wu KD. (2009/2) Comparison of residual renal function in patients undergoing twice-weekly versus three-times-weekly haemodialysis. Nephrology 2009;14(1): Chu TS, Weed HG, Wu CC, Hsu HY, Lin JT, Hsieh BS. (2009/3) A programme of accelerated medical education in Taiwan. Med Teach 2009;31(3):e74-e78. (Corresponding author) 17. Huang GS, Chu TS, Lou MF, Hwang SL, Yang RS: (2009/6) Factors associated with low bone mass in the hemodialysis patients- A cross-sectional correlation study. BMC Musculoskelet Disord 2009; Shiao CC, Kao TW, Hung KY, Chen YC, Wu MS, Chu TS, Wu KD, Tsai TJ: (2009/7) Seven-year followup of peritoneal dialysis patients in Taiwan. Periton Dialysis Int 2009;29: (Corresponding author) 19. Chen HY, Kao TW, Chiu YL, Huang JW, Lai JF, Tsai TF, Chu TS, Wu KD: (2009/7) Skin color is associated with insulin resistance in nondiabetic peritoneal dialysis patients. Periton Dialysis Int 2009;29: Lin YF, Ko WJ, Chu TS, Chen YS, WuVC, Chen YM, Wu MS, Chen YW, Tsai CW, Shiao CC, Li WY, Hu FC, Tsai BR, Tsai TJ, Wu KD: (2009/09) The 90-day mortality and the subsequent renal recovery in critically ill surgical patients requiring acute renal replacement therapy. Am J Surg 2009;198: Kuo CC, Huang CC, Chu TS: (2009/11) Renal haemophilic pseudotumor. Acta Clin Belg 2009 Nov- Dec;64(6): (Corresponding author). Letters/Case Reports Reviews 1. Chiu YL, Huang JW, Hseuh PR, Wu KD, Chu TS: (2005/8) CAPD-related peritonitis due to Salmonella enteritidis in a patient with SLE. Am J Kidney Dis 2005; 46:e21-e23. (Corresponding author) 2. Lai CF, Huang JW, Lin WC, Hung CC, Chu TS: (2006/8) Human immunodeficiency virus-associated nephropathy. J Formosa Med Assoc. 2006; 105(8): (Corresponding author) 3. Chuang YF, Chiu YL, Hwang TJ, Chu TS: (2006/10) Delirium and multiple electrolyte abnormalities associated with high dose paroxetine exposure. Psychiat Clin Neuros. 2006; 60(5): (Corresponding author) 1. Chu TS: A Report of 29 th Annual Meeting of Society of General Internal Medicine. Journal of Medical Education.2006;10; (in Chinese) 2. Chu TS, Chang CH, Hsieh BS: Internal medicine residency training in the United States. Journal of Medical 43

50 TS CHU, M.D., Ph.D Education. 2006;10: (in Chinese) 3. Kao TW, Chu TS,: Teaching at general internal medicine ward-ntuh experience. Journal of Healthcare Quality. 2008, 2(4): (in Chinese) 4. Chu TS: ACGME core competencies in general medical education. Journal of Healthcare Quality. 2009, 2(3): (in Chinese) 5. Chu TS, Weed HG, Yang PC: (2009/11) Recommendations for medical education in Taiwan. J Formos Med Assoc 2009 Nov;108(11): (Corresponding author) 44

51 Postgraduate (PGY) Training and General (Internal) Medicine Training Center 畢業後一般醫學訓練及一般醫學訓練示範中心 Tzong-Shinn Chu Secretary General Taiwan Association of Medical Education 台大醫院內科部朱宗信副主任台灣醫學教育學會秘書長 Medical Education Basic (Undergraduate) Medical Education 7-year M.D. Program after high school Postgraduate Medical Education (1) General Medicine (2) Specialty Training Continuous Professional Development 45

52 Postgraduate Training in Taiwan Problems 1. Early specialization 2. Training course: service-oriented Impacts 1. Little understanding on the holistic medical care 2. Lack of fundamental skills for medical care Reform Learn general medicine first, then specialty. Evolution of PGY Training in Taiwan 1. Establish the model of PGY in Taiwan Two-Step program, NTU College of Medicine(1998) 2. 3-month PGY general medicine training ( ) 3. 6-month PGY training ( ) 4. General (Internal) Medicine training center (2006- ) 5. 1-year PGY training (2011- ) 46

53 Schedules of the Traditional and the 2-Step Program Stage Pre-medical Basic sciences Clinical medicine Graduation First-year residency Subsequent residency Traditional Program 2 years 2 years Fifth year: clerk Sixth year: clerk Seventh year: intern Internal medicine, Surgery, Pediatrics, Obs/Gyn End of Seventh year The doctor s chosen specialty The doctor s chosen specialty Two-Step Program 2 years 2 years Fifth and sixth years Rotation as clerk: ambulatory medicine, family medicine, etc, Rotation as intern Internal medicine, Surgery, Pediatrics, Obs/Gyn End of sixth year Internal medicine, Surgery or pediatrics The doctor s chosen specialty 47

54 3-month PGY Training 1 month general internal medicine 1 month general surgery 1 month community medicine 36 hours basic training 6-month PGY Training 2 months community medicine 1 month emergency medicine 3 months specialty training Internal medicine, surgery, or pediatrics 40 hours basic training 1. Medical ethics & law 2. Evidence-based medicine 3. Quality improvement 4. Control of infection 5. Medical records writing 48

55 Taiwan PGY trend in 2003~2008 Year Number of hospitals (training/ visiting) 102/ 103/ 102/ / / / 115 Number of trainees months specialty course in 2006~2008 Internal Medicine Surgery Total class department month specialty course (the number of R1) Internal medicine surgery pediatrics 653(80.62%) 39(4.81%) 118(14.57%) 691(80.91%) 47(5.5%) 116(13.58%) 639(80.26%) 44(5.53%) 113(14.20%) 163(38.08%) 245(57.24%) 20(4.67%) 174(33.98%) 318(62.11%) 20(3.91%) 188(37.75%) 291(58.43%) 19(3.82%) 816(65.91%) 284(22.94%) 138(11.15%) 865(63.32%) 365(26.72%) 136(9.96%) 827(63.91%) 335(25.89%) 132(10.2%) Update date : 2009/08/04 49

56 General (Internal ) Medicine Training Center 1. Establish the model of general medicine training 2. Outcome-based clinical training ACGME 6 core competencies * Patient care * Medical knowledge * Practice-based learning & improvement * Interpersonal and communication skills * Professionalism * Systems-based practice 3. Faculty development Faculty Development in General Medicine Training Center Seminar of ACGME core competencies 7 hr General medicine training in practice total 40 hr Ambulatory care teaching Bedside (ward) teaching Teaching at conference Principles and practice of assessment Evaluation and feedback 50

57 Number of General (Internal ) Medicine Training Center

58 Number of Trainee Clerk Intern Resident other Number of Teaching Activities

59 Number of teacher who participated the faculty development program The departmental distribution of trained teachers (2009) Pediatrics 84 12% Emergency 71 10% Obs/Gyn 43 6% Family Medicine 73 11% Surgery % Internal Medicine % 53

60 One-Year PGY Training (2011- ) Internal Medicine 3 months: Major training hospital 1 months: Community hospital Surgery: 2 months Emergency Medicine: 1 month Pediatrics: 1 month Obs/Gyn: 1monthe Community Medicine: 2 months Elective: 1 month Core Course (Internal Medicine) Symptom & Signs: fever, dyspnea, chest pain, diarrhea, body weight loss, arthralgia, low back pain, anemia, malaise, palpitation, oliguria, jaundice, anorexia, skin rash, anxiety, depression, dizziness, sleep disturbance. 54

61 Core Course (Internal Medicine) Diseases Sepsis, consciousness disturbance, stroke, COPD, pneumonia, DM, hypertension, coronary artery disease, valvular heart disease, CHF, hepatitis, cirrhosis, GI bleeding, hematuria, respiratory failure, asthma, UTI, renal failure, cellulitis, bed sore, delirium Core Course (Internal Medicine) Procedure, interpretation and practice * EKG interpretation * CxR & abdominal X ray interpretation * Laboratory examination interpretation * Blood culture * Prevention of falling down * Identification of infectious diseases necessary to report * Recognition of emerging infectious diseases * Diagnosis & treatment of elderly patients * Palliative care 55

62 Future Plan One-Year PGY training 6 years medical school and 2 years PGY training 2006 Premedical Basic sciences Clerk intern PGY Specialty training 2011 Premedical Basic sciences Clerk intern PGY Specialty training 2018? Premedical Basic sciences Clinical sciences PGY1 PGY2 Specialty training * Patient care * Medical knowledge * Practice-based learning & improvement * Interpersonal and communication skills * Professionalism * Systems-based practice Core competencies (PGY 2011) Medical School PGY training Specialty training Examination (clinical skills) Medical license (restricted to training) Examination (clinical skills) Medical license Examination (clinical skills) Specialty board 56

63 Barriers to Developing General Internal Medicine Knowledge and Teaching Skills 1. Promotion depends upon research productivity 2. Faculty members are members of subspecialty divisions 3. Cognitive health service, including the thoughtful, selective application of testing, thorough diagnosis, careful follow-up, patient and family counseling, provision of consultation, and the management of patients with complex and concurrent health problems, such as the elderly, is reimbursed poorly, or not at all. 4. Teaching is reimbursed poorly, or not at all. Weed HG, J Med Edu ( 醫學教育 ) 2006;10:162 Suggestions for Developing General Internal Medicine Knowledge and Teaching Skills in Taiwan 1. Develop a clinical" track for academic promotion that does not require research productivity. 2. Develop divisions of General Internal Medicine. 3. Improve reimbursement for cognitive health services. 4. Improve reimbursement for teaching. 5. Develop professional organization or societies to promote learning, teaching clinical care and career advancement in GIM. 6. Support faculty members of GIM in visiting well developed divisions of GIM in other parts of the world. 7. Provide financial support to division of GIM. Weed HG, J Med Edu 2006;10:

64 58

65 中榮示範中心經驗分享吳明儒主任

67 吳明儒醫師簡歷學歷 1983/ /6 臺北醫學大學醫學院醫學士 1999/ /6 美國亞利桑那州立大學健康醫學中心研究員 2001/ /1 國立陽明大學臨床醫學研究所臨床醫學博士現任 1995 至今台中榮民總醫院內科部腎臟科主治醫師至今台中榮民總醫院內科部一般醫學內科主任至今臺灣腎臟醫學會理事至今臺灣移植醫學會理事至今臺灣腎臟醫學會教育委員會委員至今臺灣腎臟醫學會透析委員會委員至今臺灣腎臟醫學會慢性腎臟病防治委員會委員至今臺灣腎臟醫學會雜誌編輯委員會委員至今中山醫學大學醫學院醫學系兼任助理教授至今中興大學生命科學院生物醫學研究所兼任 ( 合聘 ) 助理教授至今醫策會畢業後一般醫學訓練執行輔導計畫專案小組委員至今臺灣醫學教育學會一般醫學訓練示範中心計畫工作小組委員經歷 2006/ /6 台中榮民總醫院內科部一般醫學內科訓練示範中心主任 2005/ /12 臺灣腎臟醫學會副秘書長臺灣移植醫學會監事 59

68 Ming-Ju Wu, MD, PhD Assistant Professor of Internal Medicine National Chung Hisng University and Chung-Shan Medical University, TAIWAN Dr Wu received his MD from the Taipei Medical University Medical School in Following a residency in internal medicine, he became a Clinical Fellow in the Division of Nephrology at the Taichung Veterans General Hospital. Between 1999 and 2000, he was a Research Fellow in the Division of Nephrology at the Arizona University Health Sciences Center, USA. He then continued his studies completing the PhD program at the National Yang-Ming University in Taipei. Dr Wu is an attending physician in the Division of Nephrology and the chief in the Division of General Medicine at the Taichung Veterans General Hospital. He was appointed Assistant Professor of Internal Medicine at the Chung-Shan Medical University in He is on the Board of supervisors of the Taiwan Society of Transplantation and the Taiwan Society of Nephrology. His research has been published in numerous journals including Kidney International, Journal of Cell Physiology, American Journal of Kidney Disease, Nephrology Dialysis Transplantation, Urologic Oncology and Transplantation Proceedings. 60

69 Experience of General Medical Teaching at Taichung Veterans General Hospital 一般內科教學 ~ 台中榮民總醫院經驗分享台中榮民總醫院 (Taichung Veterans General Hospital) 一般醫學內科吳明儒主任 (Ming-Ju Wu, MD, PhD) 計畫主持人藍忠亮副院長愛心. 誠信. 當責. 品質. 團隊. 創新成為全國民眾最信賴. 醫事人員最嚮往. 教學研究與經營管理最優質的標竿醫學中心一般醫學內科訓練示範中心 Ward of General Medicine at TCVGH Since March 2006 Sponsored by Taiwan Association of Medical Education under the funding of Department of Health, ROC 61

70 臨床技術中心積極支援示範中心學員核心能力訓練 Clinical Skill Center since Feb 年 96 年 97 年 98 年總計訓練場次教師人次學員人次臨床教師在臨床技術訓練中心接受各項技能教學訓練 Evidence-Based Medicine Center Popularize by seed instructor training program Assist medical residents in the process of completing a Critically Appraised Topic (From PICO to CAT) Record in the portfolios From evidence-based medicine (EBM) to evidencebased practice (EBP) 62

71 Merge into clinical practice (from EBM to EBP) 實證醫學教學融入臨床實務實證醫學課程及評量規劃和師資, 均由本院實證醫學中心規劃及安排, 課程均包含實際網路操作, 有錄影補課機制, 保障教學時段每梯次均安排未接受 UGY 訓練之學員接受補強課程以學員照顧之病患形成實證案例, 並於每週三上午安排實證醫學臨床實務小組討論專屬網站 : 有歷屆學員實證案例及 CAT 知識庫提供學員參考以教案研討會推廣實證醫學實際案例討論教學於職前訓練施行筆試及 OSCE 前測, 訓練結束前再進行後測課程雙向評估之回饋機制基本課程滿意度調查導師輔導稽核訓練課程規劃與安排 Educational Logos: Patient-centered holistic medical care Health Care Quality Infection Control Ethic and legislation EBM Patient Clinical Skill Chart Record 63

72 Six General Competencies for Residents ACGME/ABMS ( 行醫六大核心能力 ) 1. Patient Care 能照顧病患 2. Medical Knowledge 充實醫學知識 3. Practice-based learning and improvement 行醫為導向之學習與改進 4. Interpersonal communication skills 要具備人際關係及溝通技巧 5. Professionalism 要有專業精神 6. Systems-based practice 醫療體系內之行醫, 要作到全人照護 ACGME: Accreditation Council for Graduate Medical Education ABMS: American Board of Medical Specialties 36 hours basic course Conducted by Lecture Small group discussion Bedside one-to-one case-based discussion 64

73 core curriculum Quick link to Up To Date Evaluation based on different trainee and curriculum 不同訓練對象有不同的訓練目標課程和評估方式訓練對象評估方法受訓教師資深住院醫師住院醫師實習醫學生學習護照 v v V 多面向評估 (MSF) v v V 迷你臨床演練與評量 (Mini-CEX) v v V OSCE 臨床技能測驗 v v 臨床技術操作評估 (DOPS) 病歷回顧口頭測驗 (CSR) v v v 病歷寫作與修改 (Chart Round) v 六大核心能力評估 v v v 紙筆測驗 v v Healthcare Matrix OSTE 教學能力評估訓練成效評估 ( 計畫 / 受訓學員 ) v v 65

74 多元回饋 (MSF, Multi-Source Feedback) 導師教師護理及其他醫療人員測驗前簡報使學員明瞭測驗目標導師觀察學員與標準病人之互動標準病人逼真賣力演出以標準病人 (SP) 進行溝通技巧 OSCE 測驗運用標準病人能更有效地評估醫師的真實整體表現, 我們進行 " 進階溝通技巧 : 告知壞消息 " 的 OSCE 測驗, 以宣告病患得到肝癌為腳本, 利用學員導師標準病人間多方向回饋, 以目標導向式結構性評估學員之專業溝通能力學員 interview 病人後書寫記錄學員與導師及標準病人進行小組回饋全體導師學員及標準病人進行回饋 66

75 技術操作評估 (DOPS) 腰椎穿刺中心靜脈注射氣管內管插管去顫 Insertion of NG tube, Foley catheter, central venous catheter, and endotracheal tube, etc 氣管內管插入評估表訓練成效評估 ( 計畫 / 受訓學員 ) 中心靜脈導管插入評估表 Instant problem solving at Bulletin Board System : promote bi-directional communication 67

76 Program improved from feedback 學習回饋及訓練課程改善臨床教師會議暨課程規劃會議課程執行學員提出課程改善建議於臨床教師會議上檢討改善無雙向回饋 ( 考核表及核心課程意見 ) 學員座談會訓練成效評估 ( 計畫 / 受訓學員 ) 問題學員之輔導機制臨床教師或醫療團隊成員反應學員問題每週臨床教師會議提出討論導師或病房主任輔導會談已改善臨床教師於每週臨床教師會議提出報告未改善繼續訓練持續追蹤學員表現會辦學員之原屬醫院或原屬單位主管必要時予以退訓如何進行學員輔導 68

77 導師與臨床教師共同修改課程設計每週定期召開臨床教師會議每月另舉行導師及臨床教師聯席會議針對教學目標教學病例數及疾病的種類之訂定學員受訓時所擔負的責任項目與份量, 及臨床教學設施與人力安排等規劃事項與課程規劃設計負責人進行課程檢討各項課程規劃設計會議記錄及執行情形皆即時上呈計畫主持人藍忠亮副院長批示, 由藍副院長逐一親自督導執行情形訓練課程規劃與安排 Faculty Development Aggressively participating in tutor symposium organized by TJCHA Invited lectures Hosting symposium for clinical tutors (every 2~3 months) Hosting symposium for Residents as a teacher Tutor meeting (every 1~2 weeks) PGY1 project review (every month) 69

78 明訂教師獎勵辦法, 積極鼓勵教師投入教學對計畫內教師提供 PGY 訓練及鼓勵進修本院所有一般醫學訓練之教學活動均有教師鐘點費補助本院訂有 PGY 臨床教師 PPF 基本額度之保障本院各級醫師之陞遷均包含教學成效之評估本院全額補助一般醫學教師出國進修師資培育及管理 Full support for tutors to participate foreign teaching programs 院方全額補助一般醫學教師出國進修 1. 公費 (435,150 元 ) 補助派遣游棟閔醫師王賢祥醫師王建得醫師赴 96 年 9 月日英國牛津 (Oxford) 接受實證醫學教育訓練營 (EBM tutor program) 專業訓練 2. 公費 (360,336 元 ) 補助指派李博仁主任陳卷書醫師孫銘希醫師於 97 年 4 月日參加哈佛醫學大學醫學院教學技巧進階課程 3. 公費 (861,294 元 ) 補助指派傅雲慶主任陳怡行主任於 97 年 6 月日參加哈佛醫學大學醫學院醫學教育與健康照護領導人課程師資培育及管理 70

79 Symposium of teaching for tutors 積極籌辦各種研習營 ( 包含多項六大核心能力教學延伸課程 ) 研習營日期研習營名稱內科外科婦產部兒醫部其他部科院外總計 /2/14 醫學倫理研習營 - 末期病人 DNR 之醫療倫理議題 /4/2 邀請李開敏醫師專題演講 - 支持團體 /4/11 實證更新講座系列 ( 一 ) 統性回顧文獻研討會 /6/6 一般醫學教師研習營 : 如何教六大核心能力 /6/ /4/ /6/ /6/20 實證醫學更新講座系列 ( 三 ) 實證醫學進階指導者訓練共識營 - 第一梯次 98 年度畢業後一般醫學訓練 - 急診醫學實務教師培訓營實證醫學更新講座系列 ( 三 ) 實證醫學進階指導者訓練共識營 - 第二梯次實證醫學更新講座系列 ( 三 ) 實證醫學進階指導者訓練共識營 - 第三梯次 /9/24 六大核心能力延伸課程 : 專業素養工作坊 /9/26 六大能力延伸課程研習營 ( 團隊資源與管理 ) 師資培育及管理總計共 635 人次 Experiences share between tutors 各領域專長教師協助急診師資培育以提升教學品質日期學習項目授課醫師 97/04/02 教學評估 : DOPS, OSCE, mini-cex 吳明儒主任 97/08/20 教學方法陳怡行主任 97/10/08 醫病關係與溝通技巧候伯勳醫師 98/07/16 Healthcare Matrix 沈光漢主任 98/09/16 醫學倫理教學 : IDP 曾慧恩執行祕書 98/10/14 Medical Quality in PGY teaching 潘錫光主任師資培育及管理 71

80 General Medical Training Faculty development program 量身打造提供受訓教師課程課程應訓練時數實際安排時數門診教學 (outpatient) 至少 6 小時每週 15 小時以上病房教學 (bedside) 至少 4 小時每週 6 小時以上指導教學討論會至少 2 小時每週 5 小時以上評估學習 Mini-CEX OSCE 訓練成效評估回饋上課過程同步評估學員 OSTE Mini-CEX 一致性評估追踪機制師資培育及管理至少 6 小時至少 2 小時每週 5 小時以上每梯次 10 小時以上每月 2 小時以上每梯次 3 小時以上教學錄影回饋機制課程監控及提醒機制課程進行前後助理到場協助課程教師簡訊呼叫助理到場協助教師監控觀摩時間通知與電話連絡師資培育及管理 72

81 以教學影片讓受訓教師練習 Mini-CEX 一致性評估師資培育及管理優質教學團隊運作的要件適當的計畫主持人領導讓教學團隊成員都適才適所明確的教學目標願景團隊成員都能及時的溝通和支援執行公平的獎懲制度 73

82 謝謝聆聽! 敬請指導! 教學的過程其實也是一種學習 To teach is to learn twice. ~Joseph Joubert 74

83 北榮示範中心經驗分享李發耀主任

85 講師簡歷姓名 : 李發耀學經歷 : 1. 高雄醫學大學醫學系陸軍 803 醫院內科住院醫師台北榮民總醫院內科部住院醫師台北榮民總醫院胃腸科住院醫師台北榮民總醫院胃腸科總醫師國立陽明大學醫學系內科講師美國耶魯大學肝病研究中心研究員國立陽明大學醫學系內科副教授台北榮民總醫院胃腸科主治醫師現任 : 1. 台北榮民總醫院一般內科主任迄今 2. 台北榮民總醫院醫學教育中心主任迄今 3. 國立陽明大學醫學系內科教授迄今 * 95 年獲得台北榮民總醫院終身成就之醫教奉獻獎 75

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87 如何做好一般內科教學台北榮總經驗李發耀台北榮民總醫院一般內科長期以來, 國內的臨床醫學教育一直採取疾病及知識導向, 而非病人導向 ; 同時, 醫學生畢業後直接進入各專科領域接受專科及次專科住院醫師訓練, 忽視一般醫學訓練, 使得臨床醫師只會處理自己次專科的疾病, 當面對基本的臨床問題時, 卻缺乏獨立行醫的能力為了導正目前過度專科化的住院醫師訓練制度, 衛生署於民國 92 年 8 月推動畢業後一般醫學訓練計畫, 強調以病人為中心以全人醫療為宗旨的醫療照護方式, 落實美國 ACGME(Accreditation Council for Graduate Medical Education) 所認可的以六大核心能力為導向的住院醫師培訓制度此六大核心能力為以病人為中心的醫療照護醫學知識從工作中學習及成長人際關係與溝通技巧專業素養及健保制度下的臨床工作 94 年 6 月起, 更進一步針對醫學系七年級的學生推動畢業前一般醫學訓練計畫, 課程內容包括基本課程內科外科婦產科及兒科, 其中又以一般醫學內科訓練對於基本醫療能力之培養最為重要要做好一般內科教學, 除了要有專屬的訓練病房值班室會議室教師辦公室醫師室以及臨床技術訓練中心等硬體設施外, 如何進行師資培育以改善其教學技巧亦是重要關鍵臨床的教學方式與記憶存留成果息息相關, 課堂講授的記憶存留僅 5% 講義研讀約 10% 視聽電子教材約 20% 教師示範約 30% 小組討論約 50% 演練 ( 假人或標準化病人 ) 為 75%, 而實務訓練 ( 門診教學及住診教學 ) 可達 90% 在敎學過程中要注意營造教學氣氛溝通學習目標控制時間及環境讓多位學員參與持教學相長心態評估學員回饋學習成效及鼓勵自我學習為了促進學員瞭解及記憶, 進行的方式可採四階段 : 課程簡介教師示範學員演練及討論任何領域的卓越人才, 大都不是生來就有特別優秀的基因, 而是不斷地進行有計畫的訓練一般醫學教學正是醫學生蛻變成醫師不可或缺的一環教學工作需要 99 分的認同加上 1 分的訓練, 因此, 要提升醫學教學品質, 除了教師須經常參與各項教師研習活動外, 更要建立醫師對醫院永續經營及教學使命的認同, 讓臨床醫師參與教學是出於心甘情願, 而非薪甘情願 77

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89 How to Optimize Teaching at General Internal Medicine Taipei VGH Experience Fa-Yauh Lee Division of General Medicine and Medical Education Center, Taipei Veterans General Hospital Specialized ward and facilities 行政辦公室醫學倫理及法律研究室 Clinical skill exercise room 2 79

90 Clinical skill exercise room Led by a third-year resident and two registered nurses, 2-3 trainees each time 3 台北榮總臨床技術訓練中心 ( Clinical Skills Training Center, TVGH ) 80

91 60-people classroom Auditorium 20-people 人教室 classroom 10-people classroom (2) 15-people classroom (2) Simulation room 模擬診間 (2) 模擬病房 (2) Control room (2) OSCE test room Computer room Intubation model Pneumothorax model Suffocation model ACLS model BLS model Computerized ECG system 6 81

92 DxR Clinician 7 模擬人 SimMan Designed with simulated devices to mimic the management of various clinical emergencies 8 82

93 ACLS training program GYN Department Critical conditions simulation training program 83

94 Intensive care unit Critical conditions simulation training program 11 客觀結構式臨床考試 (OSCE) 12 84

95 Training program and handbooks 13 Individualized program for different trainees Program for residents 07:40-09:00 09:00-10:00 10:00-11:30 14:00-16:00 Monday Tuesday Wednesday Thursday Friday English morning meeting Evidence-based medicine New patients discussion New patients discussion Learning at ward Learning at ward General medicine teaching clinic Teaching round Teaching round Teaching round Senior teacher teaching round Teaching round Clinical skill exercise program Teaching round General medicine teaching clinic Medical ethics, journal meeting, mortality and complications discussion Learning at ward Learning at ward Learning at ward Teaching round PGY clinical skill training Teaching round General medicine teaching clinic Teaching round PGY clinical skill training Teaching round 16:00-17:30 18:00 Teaching round Teaching round Teaching round Teaching round Teaching round Combined meeting Chief round e-learning e-learning 40-hr Basic training program 40-hr Basic training program Clinical training: interpretation of ECG, CXR, KUB, liver biochemistry, perform 14 blood smear, chest tapping and case study 85

96 15 Safety protection training 16 86

97 The team on duty at general medicine teaching center nurse PGY resident Intern Third-year resident Sixth-year chief resident Attending Chief 17 Continuing education Morning meeting and seminar 9,000-10,000 per year Domestic and international conferences: 168 in 3 years Clinical medicine magazine BLS and ACLS training Medical progress training 18 87

98 Assessment 360-degree evaluation Objective structured clinical examination (OSCE) Direct observation of procedural skills (DOPS) MINI-CEX for interns Feedback: 1.Test scores reported personally 2.Inform the clinical instructor and mentor to improve the ability of those with low scores 19 核心課程滿意度 Satisfaction score of the essential programs % 95.00% 90.00% 85.00% 腦血管疾病 PGY 學員百分比 80.00% 75.00% 70.00% PGY 學員未至一般內科受訓學員 65.00% 60.00% 55.00% 50.00% 貧血胸痛腹痛水腫心悸呼吸困難發燒寡尿休克意識障礙消化道出血腦血管疾病尿路感染下呼吸道感染 / 慢性阻塞性肺病 / 氣喘糖尿病高血壓蜂窩性組織炎 / 丹毒執行血液培養心電圖判讀簡易實驗室檢查結果判讀胸部 X 光判讀單位指導老師教學指導老師給予協助總醫師或其他住院醫師給予協助值班次數滿意度照護病床數滿意度至一般內科受訓學員症狀或徵候病態或疾病判讀或執行其他 20 88

99 Bi-directionalfeedback mechanism Trainee forum Satisfaction investigation 畢業後一般醫學座談會 21 Essential programs (C) Clinical skills (7 courses) Legal problem Medical Law Medical ethics (D) Others (3 courses) Gender issue leadership multi-disciplinary team work Communication Quality PE Chart writing Others n=490 (30.9%) Clinical teacher participation Doctors n=430 (27.1%) Nurses n=665 (42.0%) 22 89

100 Essential program (A) Teaching skill(13 courses) speech tips EBM principle of teaching (B) Research capability (7 courses) Lab. management Scientific Writing clinical skill PE teaching bio-statistics study design Whole class or small groups Teaching evaluation and feedback skill

101 Training program for clinical teaching Teaching clinic OSCE Bedside teaching Mini-CEX 25 Training program for clinical teaching 8-hour specialized optional course: 1. Introduction of Training Demonstration Center, Division of General Medicine, Taipei VGH 2. Bedside teaching film (history taking, PE and communication skill) 3. PE teaching 4. EBM teaching 5. Chart writing teaching 6. Discussion 26 91

102 Research capability cultivation Encourage postgraduate studying Assign the senior doctors to instruct research performed by residents Currently organizing hospital-based mentoring program, arrange mentors for those interested in research capability development 27 Teaching method and memory retention Lecture(5%) Reading teaching material(10%) Electronic teaching material(20%) Demonstration by mentor(30%) Group discussion(50%) Practice (simulated or standardized patients)(75%) Clinical teaching(90%) 28 92

103 Teaching skills Promote memory retention (I) a. Mini-lecture b. Demonstration c. Practice by trainee d. Discussion (II) Cram-school methods Management of tachycardia Narrow QRS Herbesser (HN) Wide QRS Cordarone (WC) tachycardia = HN goes to WC 29 Skillful speech Greeting Me Environment or scene others blessings 30 93

104 Successful life Set self anticipation, no compromise (me) Adjust accordingly to face the change of environment (environment) Care for others (others) * me, environment and others 31 The best songs of Phantom of the Opera Think of me 想著我 (me) The Phantom of the Opera 歌劇魅影 (scene) All I ask of you 我對你僅有的要求 (others) * me, environment and others 32 94

105 Liver biochemistry assessment I History:19-year-old female, epigastric dull pain, abdominal fullness, poor appetite, vomiting for 1 week. Denied history of drug use and alcoholism Biochemistry: total protein 7 g/dl, albumin 4.2 g/dl ALT 3266 U/L, AST 1045 U/L, ALK-P 152 U/L, γ-gt 82 U/L bilirubin-total 5.7 mg/dl bilirubin-direct 3.6 mg/dl sugar 96 mg/dl 33 Liver biochemistry assessment II Judged by relative value ALT(X of UNL)/ALKP(X of UNL)>5 (liver cell injury) ALT(X of UNL)/ALKP(X of UNL)<2 (cholestasis) ALT(X of UNL)/ALKP(X of UNL)=2-5 (mixed type?) UNL: upper normal limit J Hepatol 1990; 11:

106 Liver biochemistry assessment III History:19-year-old female, epigastric dull pain, abdominal fullness, poor appetite, vomiting for 1 week. Denied history of drug use and alcoholism Biochemistry: ALT 3266 U/L (3266/40=82=A) ALK-P 152 U/L (152/100=1.5=B) A/B=82/1.5=55 (>5, liver cell injury) ALT(X of UNL)/ALKP(X of UNL)>5 (liver cell injury) ALT(X of UNL)/ALKP(X of UNL)<2 (cholestasis) 35 Crisis could be a turning point Minoxidil Nitric oxide 36 96

107 Administrative neutrality and prescription 37 No intake after noon and gastroesophageal reflux disease (Did budda have GERD?) 38 97

108 Cultivating the personality to success 39 The best seat superintendent aggressive passive 40 98

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110 Father of the medical educationwilliam Osler: It is a privilege to be able to participate in medical education

111 高醫示範中心經驗分享林育志醫師

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113 姓名 : 林育志出生日期 : 民國 62 年 3 月 30 日單位 : 高學醫學大學附設中和紀念職稱 : 主治醫師電話 : ext 6831 醫院一般醫學內科身分證字號 :R 住址 : 高雄市鼓山區美術東四路 396 號 13 樓之 2 學歷 ( 學校名稱主修系科學位起迄年月 ) 高雄醫學院醫學系畢業民國 80 年 9 月至民國 87 年 6 月高雄醫學大學醫學研究所臨床醫學組碩士班畢業民國 93 年 9 月至民國 97 年 6 月專科證照中華民國內科專科醫師中華民國風濕科專科醫師經歷 ( 服務機構部門職稱起迄年月 ) 高雄醫學大學附設中和紀念醫院內科部住院醫師民國 89 年 8 月至 92 年 7 月高雄醫學大學附設中和紀念醫院過敏免疫風濕內科總住院醫師民國 92 年 8 月至 94 年 7 月高雄醫學大學附設中和紀念醫院一般醫學內科主治醫師民國 94 年 8 月至今著作 ( 近五年內已發表著作之題目刊物名稱起迄頁次刊出年份若篇幅不夠可另紙填寫 ) 1. Yu-Chih Lin MD, Chen-Ching Wu MD, Tsan-Teng Ou MD, Jeng-Hsien Yen MD PhD, Hong-Wen Liu MD, and Wen-Chan Tsai MD, PhD. Malignant thymoma associated with mixed connective tissue disease: a case report. Clin Rheumatol Jul Yu-Chih Lin MD, Tsan-Teng Ou MD, Jeng-Hsien Yen MD, PhD, Wen-Chan Tsai MD, PhD, Hong-Wen Liu MD, and Chen-Ching Wu MD. Secondary Hypertroph ic Osteoarthropathy associated withmalignant Thymoma: A case report. Journal of Rheumatology, R.O.C. 2005;19 (3&4) Pei-Pei Chen, Yu-Chih Lin, Kun-Che Wu, Jeng-Hsien Yen, Tsan-Teng Ou, Chen-Ching Wu, Hong-Wen Liu, Wen-Chan Tsai. Activation of endothelial cells by antiphospholipid antibodies a possible medchanism triggering thrombosis in patients with antiphospholipid syndrome. Kaohsiung J med Sci 2006; 22: Lin YC, Wang CY, Fang TJ, Chen LI, Tsai YC, Yen JH.The general internal medicine training center at the Chung-Ho memorial hospital, Kaohsiung medical university. Journal of medical education 2007;11: Fang TJ, Hsu SC, Shih MC, Wang CY, Chen LI, Tsai YC, Lin YC. Spontaneous retroperitoneal hemorrhage in a mediastinal tumor in a patient with polymyositis: a case report. Kaohsiung J Med Sci Aug;24(8): Ou TT, Lin CH, Lin YC, Li RN, Tsai WC, Liu HW, Yen JH. IkappaBalpha promoter polymorphisms in patients with primary Sjögren's syndrome. J Clin Immunol Sep;28(5): Epub 2008 Jul 4 7. Lin YC, Huang YS, Lai CS, Yen JH, Tsai WC. Problem-based learning curriculum in medical education at Kaohsiung Medical University. Kaohsiung J Med Sci May;25(5):

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115 Building a Clinical Training Center, the experiences from General Internal Medicine Training Center, Chung Ho Memorial Hospital, Kaohsiung Medical University Yu Chih Lin MD, Jer Chia Tsai MD, Jeng Hsien Yen MD, PhD Abstract The General Internal Medicine Training Center in Chung Ho Memorial Hospital, Kaohsiung Medical University was founded in Feb 2006 and was later granted by Department of health, Executive Yuan, R.O.C. and Taiwan Association of Medical Education since Mar We believe that educational services are necessary for both clinical teaching and clinical training. A hospital based clinical training center that provides educational services and researches will be valuable for regional development of hospital clinical education. We offer programs for clinical training of undergraduate and postgraduate students, as well as teacher development programs for clinical teaching. There are also learning opportunities for clinical ethics and EBM. For the past three years, the training center has won many awards for clinical teaching and EBM. Organizational support is critical to the establishment of clinical training center. Strategic approaches regarding faculty recruitment, curriculum design, regional networking for hospital educational demands and resources are important. There are many challenges on the future of the training center including faculty development, curriculum development and finance. However, we believe that a hospital based clinical training center that provides educational services and researches will be valuable for regional development of hospital clinical education. And, it will worth our hard works. 103

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117 Building a Clinical Training Center Experiences from General Internal Medicine Training Center, Chung Ho Memorial Hospital, Kaohsiung Medical University Yu Chih Lin MD, Jer Chia Tsai MD, Jeng Hsien Yen MD, PhD Founded in Feb 2006 Brief History Granted by Taiwan Association of Medical Education (TAME) since Mar

118 Our Vision Educational services are ncecssary for both clinical teaching and clinical training. A hospital based clinical training center that provides educational services and researches will be valuable for regional development of hospital clinical education. Our missions Teaching Quality and qualified on site training programs for clinical students and teachers Service Clinical services with quality and safety Effective and efficient teaching service for regional teaching hospitals Research and Development Researches to enrich and improve clinical education 106

119 Core Faculty Jer-Chia Tsai MD Chief of the training center Yu-Chih Lin MD Tzu-Jung Fang MD Cheng-Yuan Wang MD Yi-Chun Tsai MD Jeng-Hsien Yen MD, PhD Chief of the internal medicine department Ling-I Chen MD Yung-Yun Chang MD Location, space and teaching facilities In patient care unit: Located in the 6B and 6C floor Patient capacity: 60 beds Out patient service: Two clinics, one equipped with multimedia teaching facilities Offices and Seminar rooms: Four offices, 3 for staffs and 1 for students Three Seminar rooms 107

120 Associated Departments General surgery medicine department Clinical skill center Surgical skill center Department of clinical education and training Hospital Library Training programs Clinical training programs for undergraduate year 5 6 students, year 7 students, postgraduate year 1 students, senior residents of internal medicine (TAMC qualified ) Training programs of teaching for teachers of PGY programs (TAMC qualified ) Training programs of teaching clinical ethics 108

121 Educational projects Establishment of the standard operational procedure of OSCE ( offered by TAME and by Department of health, Executive Yuan, R.O.C. ) Situated clinical ethics in Taiwan (offered by Department of health, Executive Yuan, R.O.C.) Learning opportunities We also offer customized on site learning opportunities for Clinical ethics case writing, reasoning, case analysis EBM, EBN Clinical teaching and assessment 109

122 Regional teaching services We also go to regional teaching hospital to offer or participate in educational programs for clinical training or faculty development. Our services cover the following area Tainan city and county (2 hospitals) Kaohsiung city and county (4 hospitals) Ping Tung city and county (2 hospitals) Awards Qualified by TAME as Excellent training site for 3 years ( 2007, 2008, 2009) Faculty and students participated in national EMB competitions by TJCHA, winning 2 silver medals in 2007 and 2 golden in Excellent clinical teaching department and excellent teachers in KMUH for 3 years. 110

123 Major issues from our experiences Organizational supports Faculty recruitment and development Curriculum development Regional networking of educational demands and resources From a steering force of new clinical educational policy to an educational service center Organizational supports Financial and administrative supports were granted generously from the superintendent of KMUH. Supports from the all over the department of internal medicine and its associated divisions. 111

124 Faculty recruitment and development Recruiting young staff Carrier planning issues Promotion system Faculty development Training of teaching skill and curriculum planning Developing specialized teaching ability Curriculum development Curriculum design Developing format Writing and planning a curriculum for different group of students Update and remodeling of curriculum Making learning objectives according to needs ( policy or student s needs) Feasible and appropriate teaching methods and assessments 112

125 Regional networking of educational demands and resources A training center that provides fundamental education to medical professions that will serve at every level in our medical system. Regional networking of hospitals and clinics will be important to direct our educational goal up to the needs of medical services. Regional networking may be important to maintain the business of educational services. Educational services Training services Offering training programs for a variety of trainee Teaching services Providing in hospital and regional teaching assistances and educational program Collaboration of educational researches Providing resources of educational research for university professoriate 113

126 Challenges Factors that bring about our challenges National medical education policy Demands for educational services Academic development Others ( market, organizational factors, etc.) Challenges Faculty recruitment and development Unique personal carrier planning and uncertain future The non commercial nature of education services and fading financial support The requirement of further and in depth professional/academic education of medical education 114

127 Challenges Curriculum development The ever changing society, medical education policy and students. Needs assessment is always required. Curriculum for hospital medical training to fulfill the needs for regional medical service. Challenges The needs of teaching and training services never stay the same. Others, many uncertainties 115

128 Summary We are thankful to have the opportunity and supports offered by TAME to build up a clinical training center in KMUH. Organizational supports, strategical approaches and enthusiasm of faculty are critical on the way to build a training center. Thank you for attentions! 116

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131 NEWS AND PERSPECTIVES Recommendations for Medical Education in Taiwan Tzong-Shinn Chu, 1,2 * Harrison G. Weed, 3 Pan-Chyr Yang 2 Background Biomedical research performed in Taiwan is published in top medical journals, and the latest therapeutic innovations, such as biopharmaceuticals, cardiac electrophysiology and robotic surgery are available in Taiwan. However, primary medical care in Taiwan currently is inadequate, and as the population of Taiwan ages, the need for primary care will increase. Good primary care is necessary to ensure that diseases such as hypertension, diabetes and cancer are detected and treated early, to identify people who might benefit from the latest therapeutic innovations, and to identify rapidly and respond effectively to emerging health threats such as multidrug-resistant pathogens. Here, we report briefly a pathway of accelerated medical education that reduces the time spent in the classroom and increases the time spent learning clinical fundamentals. We propose widespread adoption of similar educational pathways and reform of other aspects of medical education in Taiwan, to facilitate the training of doctors who can provide the primary care needed by the people of Taiwan. Six aspects of medical education in Taiwan contribute to the poor preparation of doctors to provide primary care. (1) Insufficient training in clinical fundamentals including humanism, history taking, physical examination and the biopsychosocial model of medical care. (2) Insufficient training in quality improvement, including how to recognize improvement opportunities, how to motivate change, and how to improve quality by making systemic changes. (3) No formal training in teamwork. Teamwork is essential for quality medical care, but medical students are graded on individual performance. Similarly, teamwork is disregarded at more advanced levels of medical training. Consequently, teamwork is neglected in medical practice, which results in poor coordination among health professionals and therefore poor medical care. 1 (4) Insufficient outpatient primary care training. Current medical training primarily is hospital-based. Doctors have the knowledge and skills to provide highintensity, high-technology, high-cost and acute medical interventions, but not to provide primary care. (5) Early specialization. When trainees specialize early, they truncate their education in fundamental clinical skills and focus on acquiring the knowledge and techniques of a narrow field of practice. As a consequence, they never gain the knowledge or the skills needed to provide primary care, or to teach it. (6) Finally, faculty physicians depend on fee-for-service National Health Insurance for their income, but this 2009 Elsevier & Formosan Medical Association Departments of Primary Care Medicine and 2 Internal Medicine, National Taiwan University College of Medicine and Hospital, Taipei, Taiwan; 3 Division of General Internal Medicine, The Ohio State University College of Medicine, Columbus, Ohio, USA. *Correspondence to: Dr Tzong-Shinn Chu, Department Internal Medicine, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, Taiwan. [email protected] 830 J Formos Med Assoc 2009 Vol 108 No

132 Recommendations for medical education reimbursement system does not compensate them for teaching or developing their teaching skills. Consequently, the teaching practices and skills of faculty physicians are poor, 1,2 and a system of compensating them for teaching is needed. Six structural aspects of medical training in Taiwan have contributed to a health system that provides high-technology acute care, but not comprehensive primary care. We must reform medical training to improve primary medical care in Taiwan. One aspect of reforming medical training is to reduce the time that students spend in classroom-based learning and thereby allow more time for learning clinical fundamentals, quality improvement, teamwork and outpatient care. The National Taiwan University College of Medicine Experience In 1998, the National Taiwan University College of Medicine (NTUCM) initiated an ongoing twostep program to accelerate undergraduate medical education and to teach students in general clinical care before they commit to specialist training. In the first step, selected students entering their fifth year of medical school undergo 1 month of clinical skills preparation, and then undertake the clinical rotations usually done in the sixth and seventh years. In addition, more than half of these clinical rotations are designed to teach fundamental clinical skills, quality improvement and teamwork. At the end of the sixth year (instead of the usual seventh year) students graduate and are qualified to sit for the National Medical Certifying Examination. The second step of the program is a compulsory year of postgraduate training in general clinical skills in one of three specialties: internal medicine, surgery or pediatrics. Broad training continues during the year, for example, residents in surgery spend 1 month as internal medicine residents and 1 month as community medicine residents. Compared with students who receive traditional instruction, those selected for the two-step program are more likely to pass national board examinations (100% vs %), and have been rated as more proficient by their teachers for nine different parameters of clinical performance (p < 0.001). 3 Although the outcomes of the NTUCM two-step program have not been analyzed to assess the impact on primary care, there is evidence that the classroom portion of undergraduate medical education can be shortened by 1 year, which allows an extra year for students to develop practical clinical knowledge and skills. Recommendations Implement the Postgraduate Year Residency (PGY) program nationwide by 2011 From August 2003, the Department of Health in Taiwan promulgated a program of 3 months of broad education in the first postgraduate year, which consisted of at least 36 hours of basic training, and 1 month of training in general surgery, internal medicine and community medicine. From August 2006, residents began participating in the formal PGY program. The program is divided into two halves of 6 months each. The first half consists of 1 month of general clinical training, 1 month of basic community medicine, 1 month of community-related medicine, and 3 months of specialty training in internal medicine, surgery or pediatrics. To date, two-thirds have chosen internal medicine. 2 This half of the PGY program is organized and overseen by the Taiwan Joint Commission on Hospital Accreditation (TJCHA). The second half of the PGY program consists of 6 months of medical training in the resident s chosen specialty, and is organized and overseen by individual hospitals with reference to official guidelines. We recommend the following: (1) Fully implement the PGY program in (2) Do not allow specialty training programs to offer trainees positions, and do not allow trainees to commit to specialty training programs, until after they have completed the PGY program. (3) Grade trainees in the PGY program (A, B, C and D, where A is excellent and D is failing ). Explicitly J Formos Med Assoc 2009 Vol 108 No

133 T.S. Chu, et al define grading criteria and apply them consistently across programs. (4) Encourage teaching hospitals to submit proposals for participation in the PGY program to the Department of Health or another suitable authority for official review and oversight. (5) Provide half of the salary of a trainee in the PGY program through the Department of Health. (6) Include the PGY program in the residency matching process. (7) Administer the PGY program through departments of medical education at teaching hospitals. Reform teaching, certification and training program accreditation Traditionally, medical students in Taiwan have been taught by lectures and graded by written examinations. These methods of teaching and grading devalue curiosity, creativity, humanism and teamwork, which are all critical aspects of providing good healthcare. Supervising doctors, clinical teachers and program directors report that many trainees do not take an active role in learning, and encouraging trainees to do this will require changing the learning environment. The TJCHA has established a nationwide system for development of medical teachers, which includes a core curriculum and materials designed to help medical educators develop their skills in student assessment and providing feedback. Based on data collected by the TJCHA, when medical educators use these materials, trainees feel that their clinical experience is enhanced and their learning environment is improved. 2 To enhance the clinical experience and improve the learning environment, there must be substantial changes in examination, certification and accreditation. Trainees must be held to specific, high standards to progress to the next level of training. Teaching hospitals also must be held to specific, high standards to maintain certification of their residency programs. Medical education reform must start with undergraduate education. The recently published Medical School Objectives Project, a series of reports from the Association of American Medical Colleges, could be a useful reference in this process. 4 Also, in the same way that certification should be used to enforce specific standards on postgraduate teaching programs, medical school accreditation should be used to enforce specific curriculum and teaching reforms. Medical schools in Taiwan should replace the traditional curriculum and lecture-style teaching with integrated, problem-solving, active learning and learnercentered programs, to improve undergraduate medical education and teach students life-long learning habits. Research has demonstrated that such programs can increase self-directed learning and improve educational outcomes. The current national medical licensure examination in Taiwan focuses on pathophysiological medical knowledge, without addressing medical ethics or the doctor patient relationship, and no requirement for demonstration of clinical skills. For certification, the Department of Health should require trainees to pass a core clinical skills examination similar to step 3 of the United States Medical Licensing Examination. This examination should be administered at the end of the PGY program and passing it should be a requirement, both for certification and entering specialty training. The core clinical skills examination should use standardized patients and objective measures of clinical performance, such as those in an objective structured clinical examination (OSCE). The Taiwan Association of Medical Education has established an OSCE task force, and is promoting actively OSCEs nationwide. A core clinical skills examination currently is required in the United States, Canada and Japan, and it is time for Taiwan to adopt modern methods of assessing qualifications for medical licensure. 5,6 Shorten medical school education to 6 years Six years of medical school followed by 2 years of general clinical training is standard in many countries including the United Kingdom and Japan. 6 Adopting a similar system in Taiwan has the potential to improve the quality of medical education and the medical care that is provided to the people of Taiwan (Figure). 832 J Formos Med Assoc 2009 Vol 108 No

134 Recommendations for medical education (I) Medical school education (6 yr) (II) Postgraduate training (2 yr) (III) Specialty training (2 3 yr) (IV) Subspecialty training (2 3 yr) Primary care Figure. Proposal for a new clinical training system. (I) Shorten medical school education to 6 years, with general education and humanities in the 1 st and 2 nd years; integrated basic medical sciences in the 3 rd and 4 th years; and clinical teaching in the 5 th and 6 th years. Internship will be provided after graduation. (II) A 2-year compulsory postgraduate training. The first year will be general clinical training comparable to the current intern year, but with higher standards. The second year will be clinical training in community medicine and general internal medicine, general surgery, or general pediatrics. (III) Successful completion of the 2-year program will be required for a doctor to enter general medical practice or to start specialty training. (IV) Determine the number of positions available for subspecialty training based on national needs. Reform reimbursement Specific barriers to providing medical education are that there are too many patients seen per clinic in a teaching setting, and that long work hours do not allow time for learning or teaching, or for teachers to develop their teaching skills. The fundamental reason for this work overload is that reimbursement for clinical care provided in teaching settings is insufficient. Therefore, to improve medical education, the National Health Insurance system will need reform, including that specific to the special needs of clinical care provided in a teaching setting. The Department of Health could subsidize the cost of clinical teaching. 2 Of course, medical education is not responsible exclusively for poor primary care in Taiwan, and changes in medical education will not by themselves improve primary care in Taiwan. However, we think that the above changes in medical education are necessary to reach the goal of providing the primary care that the people of Taiwan deserve. References 1. Chu TS. Health professions education. Taipei: Taiwan Joint Commission of Hospital Accreditation 2007: [In Chinese] 2. Hsieh BS. General medical education, 2 nd edition. Taipei: National Taiwan University College of Medicine 2006: [In Chinese] 3. Chu TS, Weed HG, Wu CC, et al. A program of accelerated medical education in Taiwan. Med Teach 2009;31:e The Medical School Objectives Writing Group. Learning objectives for medical school education: guidelines for medical schools. Report I of the Medical School Objectives Project. Acad Med 1999;74: Association of American Medical Colleges, Task Force on the Clinical Skills Education of Medical Students. The AAMC project on the clinical education of medical students. Washington DC: American Association of Medical Colleges 2005: Teo A. The current state of medical education in Japan: a system under reform. Med Educ 2007;41: J Formos Med Assoc 2009 Vol 108 No

135 美國內科住院醫師訓練朱宗信 1,2 張家勳 2 1,2 謝博生美國住院醫師訓練的目標依 Accreditation Council for Graduate Medical Education 的建議是培訓住院醫師六項核心能力, 即病人照顧醫學知識臨床工作中的學習與改善人際關係與溝通技巧專業素養, 以及制度下的臨床工作多數醫學院內科提供的住院醫師訓練分為三大類 : 一為傳統路徑 ; 二為 primary care internist 路徑 ; 三為 preliminary 路徑在美國, 為便於住院醫師訓練, 內科病房大多是一般內科病房住院醫師的門診及急診訓練占訓練總時數三分之一以上內科住院醫師訓練期間為三年, 包括至少 30 個月的一般內科內科次專科加護醫學急診醫學訓練近幾年來, 美國內科住院醫師訓練完畢者每年約 7 千名, 內科專科執照通過率約 90% 目前美國內科執業模式可分為三類:一般內科醫師住院病患專責醫師次專科醫師為了拉近住院醫師訓練與執業之差距, 住院醫師訓練時間要合理分配到各項執業模式並執行高品質安全有效全人醫療之訓練關鍵詞 : 美國內科住院醫師訓練 ( 醫學教育 2006;10:267~75) 23% 7 8% 1 2% 前言 5% [2] Accreditation Council for primary care primary care 4 十 40 50% [1] 9 11% 20 Graduate Medical Education, ACGME patient care medical knowledge practicebased learning and improvement interpersonal and communication skills professionalism system-based practice [3] [email protected] 121 醫學教育第十卷第四期 2006

136 268 朱宗信張家勳謝博生 25 [4] trainingpractice gap pay for performance [5] [6] [5] 訓練計畫 ACGME 十 [7] 簡介一內科的定義及範圍二訓練期間及範圍三訓練標準機構一主要訓練機構二參與機構計畫人力及資源一計畫主持人二教員三其他人員 J Med Education Vol.10 No

137 美國內科住院醫師訓練 269 四資源住院醫師任命一可被選為住院醫師之條件 osteopath Educational Commission for Foreign Medical Graduate, ECFMG 二住院醫師數目 ACGME 12 三住院醫師轉換計畫課程一課程設計二課程三住院醫師學術活動四 ACGME 臨床能力 ACGME 五講授式教學 grand rounds 150 六臨床醫學教育第十卷第四期 2006

138 270 朱宗信張家勳謝博生 X 六工作時數例外狀況 80 七服務與教學八逐漸增加的責任九委屈及申訴工作時數及環境一監督下之訓練二工作時數三值班四兼職五監視管理評估一住院醫師 1. formative 2. 二教員三訓練計畫實驗及創新 AC- GME 專科證書 American Board of Internal Medicine, ABIM J Med Education Vol.10 No

139 美國內科住院醫師訓練 271 訓練內容及執行訓練路徑 primary care internist preliminary primary care physician [8] transitional 病房訓練 [9] 門診訓練 8 4 [10] 師資 [10] [11] 十 hospitalist [12] 評估方法 degree evaluation instrument chart stimulated recall oral examination, CSR checklist evaluation of live or recorded performance global rating of live or recorded performance objective structured clinical examination, OSCE procedure, operative, or case logs patient surveys portfolios record review simulations and models standardized oral examination standardized patient examination written examination, MCQ [13] 125 醫學教育第十卷第四期 2006

140 272 朱宗信張家勳謝博生 360 度評估法病歷刺激回憶口試實作評估表式評估病歷複查模擬及模型標準化口試實作全面評分客觀結構式臨床測驗操作手術或病例工作簿標準化病人測驗筆試 ( 選擇題 ) 敘 4 5 內科專科考試及認證病患調查學習歷程 [14] J Med Education Vol.10 No

141 美國內科住院醫師訓練 % 70% 2 3 certificate of added qualification, CAQ [15] 建議誌謝 Cindy Lai 參考文獻 1. Newton DA, Grayson MS: Trends in career choice by US medical school graduates. JAMA 2003; 290: Brotherton SE, Rockey PH, Etzel SI: US graduate medical education, JAMA 2005; 294: Accreditation Council for Graduate Medical Education: ACGME outcome project: general competencies. Available at com/compfull.asp. Accessed December 27, Charap MH, Levin RI, Pearlman RE, et al: Internal medicine residency training in the 21st century: aligning requirements with professional needs. Am J Med 2005; 118: Arora V, Guardiano S, Donaldson D, et al : Closing the gap between internal medicine training and practice: Recommendations from recent graduates. Am J Med 2005; 118: Larson EB, Fihn SD, Kirk LM, et al: The future of general internal medicine. J Gen Intern Med 2004; 19: Accreditation Council for Graduate Medical Education: Program requirements for residency education in internal medicine. ACGME, Department of Medicine, The University of Washington: Description of residency pathways. Available at residency/pathways.html. Accessed December 27, ; 4: Department of Medicine, The University of Washington: Division of General Internal Medicine. Available at Accessed December 27, Wachter RM: Hospitalist in the United States-mission 127 醫學教育第十卷第四期 2006

142 274 朱宗信張家勳謝博生 accomplished or work in progress? N Engl J Med 2004; 350: Accreditation Council for Graduate Medical Education: Toolbox of assessment methods. ACGME, American Board of Internal Medicine: Policies and procedures for certification. ABIM, American Board of Internal Medicine: Certification. Available at shtm. Accessed December 27, J Med Education Vol.10 No

143 Internal Medicine Residency Training in the United States The Accreditation Council for Graduate Medical Education (ACGME) of the United States has endorsed general competencies for residents in the areas of patient care, medical knowledge, practicebased learning and improvement, interpersonal and communication skills, professionalism, and systems-based practice. Departments of internal medicine in American medical schools provide three internal medicine residency pathways: a preliminary pathway, the traditional pathway, and the primary care internist pathway. Most internal medicine wards are general wards. A minimum of 1/3 of training time must be spent in ambulatory sites. The 36 months of full-time medical residency education must include at least 30 months of general internal medicine training, subspecialty internal medicine, critical care medicine, and emergency medicine. From 2001 to 2005, there were about 7000 first-time takers of American Board of Internal Medicine (ABIM) Internal Medicine Certification Examination per year, and their pass rates were approximately 90%. It is recognized that internal medicine practice has evolved three models of practitioners: general internists, hospitalists, and subspecialists. To close the training-practice gap, internal medicine training must provide a balanced allocation of time for each practice model, as well as additional education aimed at understanding and using tools for delivering safe and effective, high-quality patient care. (Full text in Chinese) Key words: United States, internal medicine, residency training. ( J Med Education 2006; 10: 267~75 ) 1 Department of Primary Care Medicine, National Taiwan University College of Medicine; 2 Department of Internal Medicine, National Taiwan University College of Medicine and Hospital. Received: 11 May 2006 ; Accepted: 30 December Correspondence to: Tzong-Shinn Chu, Department of Internal Medicine, National Taiwan University Hospital, 7 Chung-Shan South Road, Taipei, Taiwan. [email protected] 129 醫學教育第十卷第四期 2006

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147 對台灣一般內科醫學教學的感想與建議一個國家的健康照護系統如植基於基層門診照護並建構連續性照護, 則其國人較健康且花費也較少然而台灣現行的健康照護系統迥然不是如此在我的印象中, 台灣的健康醫療照護系統是基於次專科的照護, 由個人各自獨立的門診照顧病人通常其設計在於獲得最大利益, 而無品質的監督在台灣, 大學醫學院內科部門的所有教員皆為次專科醫生由於過於早期並嚴格的專科化, 以及學術職位升遷以研究成果為考量的結果, 極少大學醫學院內科教師能夠具備教授內科的基本知識和教學技巧此基本知識及技能包括 : 廣泛而多層面的問診 ; 行使理學檢查 ; 實驗診斷檢查結果的判讀, 合理的診斷, 以及對病人的諮商當然, 台灣有許多醫生是具有熱誠, 並與生俱有極佳的能力, 能夠成為優良的老師, 然而這些醫生們在現行台灣的醫療體系以及醫療教育系統之下, 在尚未發展成為優良教師之前即遭扼殺關於發展一般內科醫學的知識和教學技巧的阻礙有以下四項 : 一職位的升遷完全取決於研究成果對於耗時於推展一般醫學知識及教學改進而疏於其它研究及論文發表者, 被視為不適於升遷且對系所院校無所貢獻二教職人員皆為次專科成員, 因此他們的責任和義務皆著重於次專科的需要任何費時推展一般醫學知識及教學方面的改進, 而非關注於次專科的進展者皆被視為對其部門無所貢獻三對於要用頭腦的醫療服務不肯定且給予極少酬償此類工作項目包括 : 貼切選擇適當的檢驗 ; 徹底仔細的診斷 ; 細心的追蹤病情, 對於病患及其家屬的諮商 ; 提供照會 ; 以及處理複雜及有併發症狀的病人, 如老年人等四教學工作的酬償是非常微薄或甚而完全闕如在台灣, 有許多醫生是與生俱有良好的能力與性向, 可成為優秀的老師, 他們為了教學寧願忍受較緩慢的升遷或較微薄的待遇然而, 假如障礙太大, 有如現存狀況, 那麼願意選擇犧牲去跨越如此的障礙者, 大概是微乎其微了有關於發展台灣一般內科醫學知識及教學技巧的建言如下 : 一建立一套臨床醫學從事者在學術界升遷的管道升遷不受限於研究成果產量此臨床升遷的管道需另外採行紀錄其工作之評量結果, 包括 : 提供可作範例的臨床照護或教學 ; 在國家或學術機構執行臨床照護或教學改進的計畫 ; 以臨床或教學為主題發表論文要注意的是, 此臨床升遷管道的發展, 必須要建立並採用一套評估臨床照護和教學的制度和系統 133

148 二發展一般內科醫學部門, 使其成為一獨立於次專科部門的單位雖然此一般內科部門的教員, 或許已接受其它次專科的訓練, 然而其薪資升遷及職責派定皆來自一般內科部門而非次專科部門一般內科醫學部門的教職成員可接受進一步的訓練, 並取得各種特別的資格認定例如 : 他們可修習取得老人醫學證書 ; 也可攻讀教育學統計學臨床研究健康服務研究, 或公共衛生等方面的碩士學位三增加須花心思的醫療服務之酬償, 此或許需要一套電子醫學記錄檔案, 登載照護品質的評量記錄, 並且易於審閱酬償即可取決於提供照護的品質四改進教學工作的酬償工作品質評量的文件紀錄檔案也需要加強五發展一般內科專業組織或學會以提昇一般內科的學習臨床教學及專業發展此類組織可能需要外界 10 年至 15 年的資助, 直至大量的一般內科醫生可成長至自給自足六資助一般內科醫學部門的教員赴在此領域已充分進展的國家參訪學習此類訪問可以是參觀, 接受訓練, 或其它進修, 其目的為將學習所得帶回台灣, 以資貢獻七在其它國家, 一般內科部門並非自我獨立維持的部門一般內科醫學的學術部門無法單獨從其臨床及教學的收入來支付其教職人員的薪資因為一般內科部門是著重在花心思的醫療在醫學中心的其它部門和次專科部門, 其收入可來自檢查處置費用以及其擁有的診斷性檢驗設備這些在一般內科部門是闕如的是故一般內科部門無法直接自臨床收入得到足夠的經費而自給自足因此一般醫學部門應做到下列數點 : 1. 徹底的做到文書登載他們對醫學中心的貢獻, 並且推展這些貢獻實例, 以使其它部門能夠了解認知 2. 和醫學中心內各部門學校社會共同合作 3. 尋求創造經費的收入來源, 其方式如下 : (1) 對其它部門的提供服務, 並自其直接取得費用的轉移 (2) 給予教學者明確而充分足夠的薪資 (3) 補助研究經費 (4) 藉由自病患或慈善團體的捐贈貢獻和補助經費來提供特殊的專業的教職人員, 教學及學生的各項活動 (5) 醫學中心間接轉移並提供部分的臨床經費, 例如經常性的診療開銷, 或補助臨床收入大多數的一般內科醫學部門都發現一件事實, 即為基於獎勵而增加部分薪資是很有助益的, 也就是在提出或接受研究補助或是執行臨床或教學服務, 超越某一期待的底線之上時, 給予薪資獎勵上述所列如能有所改變是需要台灣的醫療照護系統多方面的行動配合其包 134

149 括內科醫學部門醫學院大學教育部衛生署及健保局在美國此項改變工程始自二十年前, 至今尚未完成這似乎是一條漫漫長路, 但卻值得探尋, 因為隨著此路途, 台灣的醫療照護體系將會有所改進俄亥俄州立大學醫學院一般內科醫學部臨床內科醫學教授 Harrison G. Weed, MD, MS, FACP 中譯林佩瑩台大醫院內科部朱宗信台大醫院內科部台大醫學院一般醫學科 135

150 136

151 一般內科教學研討會活動問卷一基本資料 1. 性別: 男女 2. 職稱: 醫學院教師主治醫師其他二研習成果評值 1. 本研討會安排如何做好一般內科教學及美國一般內科現況之議題對您助益程度如何? 非常有幫助有一點幫助普通無助益無任何助益其他意見您對該議題的主講者是否滿意? 非常滿意滿意普通不滿意非常不滿意其他意見 2. 本研討會安排畢業後一般醫學訓練與一般醫學訓練示範中心之議題對您助益程度如何? 非常有幫助有一點幫助普通無助益無任何助益其他意見您對該議題的主講者是否滿意? 非常滿意滿意普通不滿意非常不滿意其他意見 3. 本研討會安排台中榮總經驗之議題對您助益程度如何? 非常有幫助有一點幫助普通無助益無任何助益其他意見您對該議題的主講者是否滿意? 非常滿意滿意普通不滿意非常不滿意其他意見 4. 本研討會安排台北榮總經驗之議題對您助益程度如何? 非常有幫助有一點幫助普通無助益無任何助益其他意見您對該議題的主講者是否滿意? 137

152 非常滿意滿意普通不滿意非常不滿意其他意見 5. 本研討會安排高醫附醫經驗之議題對您助益程度如何? 非常有幫助有一點幫助普通無助益無任何助益其他意見您對該議題的主講者是否滿意? 非常滿意滿意普通不滿意非常不滿意其他意見 6. 整體而言, 此次課程對您個人的收穫非常滿意滿意普通不滿意非常不滿意三其他建議此次研習活動, 您有無其他任何建議事項 ( 課程主題講義資料活動場地時間安排.), 敬請不吝提供給我們! 謝謝您的填寫! 台灣醫學教育學會敬上 138

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