臺灣博碩士論文加值系統

一直以來，外科系住院醫師的養成教育多採用學徒制度模式，因著醫療科技的大幅進步、醫療經濟學的發展、疾病嚴重度的增加、以及社會大眾的高度期待，過去十年，國外在外科醫學教育這方面有大幅度的進步，主要是導入能力為基礎的新外科教育模式，企圖在工作時數限制及臨床學習機會減少的困境下，藉由在外科技術實驗室推動建構性訓練課程，培養新一代外科醫師具備良好的臨床能力。本研究是關於「建構式外科技能訓練模式」--結合基礎手術訓練及進階動物實驗訓練，在新設立的台大醫院微創手術訓練中心進行，藉由多項評估方式，評估課程成效、臨床表現、以及對外科醫師養成能力的影響三個方面的訓練成果，採量化及質性混合型研究設計，找出此一嶄新的訓練模式，對住院醫師在外科醫師能力培養的影響因素。研究結果顯示，本研究提出的「建構式外科技能訓練模式」，的確能達到培養外科能力之目的。所培養的能力包括各項基本及進階手術技能、領導能力、團隊合作能力、教學能力，因此，不僅增進外科第一、二年住院醫師的基本手術能力及對自我能力了解的程度，也提升了其成為一位優秀的外科醫師的自信心。關於「建構式外科技能訓練模式」培養的基本手術能力與臨床表現的關係，本研究量化結果僅發現動物實驗縫合整體表現和門診手術第四週評估皮下腫瘤切除整體表現，有高度相關，但訪談結果可佐證，在無壓力可以討論的學習環境中，藉由設計良好的訓練課程，本訓練模式所培養的基本手術能力是能運用到臨床工作中。「建構式外科技能訓練模式」能提升住院醫師成為優秀外科醫師的自信心，是一個有效且具培養多種能力的訓練模式。

Competency-based surgical training models with hands-on skills training in surgical skills laboratories are the new trend for cultivating new surgeons. We assessed the effect of the new National Taiwan University Hospital Structured Surgical Skill Training Model (NTUH SSSTM) on the development of young surgeons’ competencies. We set up new basic surgical skills (BSS) training workshops in Minimally Invasive Surgery Training Center, NTUH in 2008, which combined to advanced animal experiments for junior residents as the NTUH SSSTM. The BBS training workshops included basic surgical skills, small bowel anastomosis, subcutaneous tumor excision and usage of auto-suture devices. Junior residents performed diagnostic laparoscopy and subtotal gastrectomy on pigs and performed exploratory laparotomy 2 weeks later. Mixed method reseach was conduted included self-evaluated questionares for both training courses, sugical skills assessment forms for suturing, kot tying, bowel anastomosis, subcuteneous tumor excision, an interview study for the trainees, and a group discussion for the trainers.

The results of self-evaluated scores of both courses showed the young trainees gained competency significantly in performing basic and advanced surgical skills. The competences which included basic and advanced surgical skills, leadership, teamwork, and teaching ability were cultivated in this training model. Young surgical trainees and surgical trainers thought these competences could be implemented in the clinical setting. In conclusion, the National Taiwan University Hospital Structured Surgical Skill Training Model was an effective model which could cultivate multiple competences in order to increase a young surgical trainee’s confidence in order to become an excellent surgeon in the future.

第一章 緒論 1
第一節 研究動機 1
第二節 研究目的與問題 3
壹、研究目的 3
貳、研究問題 3
第二章 文獻探討 5
第一節 各國外科住院醫師訓練概況 5
壹、美國 5
貳、歐洲 8
參、澳洲及紐西蘭 13
肆、日本 14
伍、台灣 15
第二節 目前外科住院醫師訓練的困境 16
壹、工作時數限制 16
貳、手術經驗短缺 17
第三節 以能力為基礎的外科教學新模式之定義與評估方法 19
壹、外科臨床能力的定義 19
貳、外科臨床能力之評估方法 20
第五節 外科技術實驗室學到的技巧如何延續到工作中 24
第三章 研究方法 27
第一節 研究架構與設計 27
第二節 参與者 28
第三節 建構式外科技能訓練模式施行方式 28
第四節 實施流程 31
第五節 研究工具 34
第六節 資料處理與分析 37
第四章 結果與討論 39
第一節 各項自我評估問卷及評估表信度及效度分析 39
第二節 手術基本技術研習營（BASIC SURGICAL SKILLS WORKSHOP）訓練成效分析 42
第三節 診斷性腹腔鏡及次全胃切除動物實驗（ANIMAL LAB WITH DIAGNOSTIC LAPAROSCOPY AND SUBTOTAL GASTRECTOMY）訓練成效分析 50
第四節「門診手術基本技術」評核結果分析 57
第五節 參訓學員訪談結果分析 62
第六節 指導老師團體討論結果分析 81
第七節 討論 91
第五章 結論與建議 95
第一節 結論 95
第二節 建議 95
參考文獻 97
附錄.... 101
附錄一 「手術基本技術研習營」訓練前、後自我評估問卷 101
附錄二 「基本手術器械介紹」評核表 102
附錄三 「動物實驗—診斷性腹腔鏡及次全胃切除手術」訓練前、後自我評估問卷 103
附錄四 「腸道吻合(BOWEL ANASTOMOSIS)技術」評核表 104
附錄五 「門診手術基本技術」評核表 105
附錄六 參訓學員半結構式訪談大綱 107

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