近年來醫療服務的觀念皆強調以病人為中心，醫學教育的方向也除了傳統醫療知識傳授，更著重技能的訓練與態度的培養。牙醫師的臨床技能需要被確實教導與評量是無庸置疑的，臨床實作評量 (Performance Assessment)，而其中又包含了客觀結構式臨床測驗 (Objective Structured Clinical Examination, OSCE)，應用於牙科的訓練成效評估，已在各國實施多年，目的是利用實際操作來檢視牙醫學生面對醫療工作是否已經具備足夠的臨床能力。許多研究顯示藉由OSCE 比紙本筆試更能評量學生真正之臨床能力。因此OSCE便成為評量臨床技能的重要工具之ㄧ，近年來更成為美加與日本醫師執照考試的一部份，如：醫病溝通、病歷詢問及臨床診察技巧等測驗。
臺灣大學牙醫專業學院為提昇牙醫學教育品質，成立OSCE 小組，進行包括試務指引開發及教師訓練。小組進行資料收集與文獻回顧，藉由探討各國核心能力訂定之異同及運用名義團體技巧 (Nominal Group Technique) 訂定本院牙醫學系學生畢業時需具備之臨床核心能力，並據此確定本院OSCE之配題藍圖 (blueprint)。在一系列之教師訓練課程後，接著進行考題開發，並利用迷你-客觀結構式臨床測驗 (mini-OSCE) 進行考官信效度測試，最後進行院內三個不同階層共三十六位學生進行六站之OSCE，測驗結果除可提供臨床教師擬定教學內容和未來修正課程規劃的方向外，亦希望本考試之建構過程亦可提供各牙醫學院後，於在未來推行OSCE 時做為參考。

關鍵詞：臨床實作評量、客觀結構式臨床測驗、名義團體技巧

The concept of “Patient Center” is emphasized in the medical care recently. Dental education in addition to the traditional medical and dental knowledge, more focus on the development of skills and attitudes. Without a doubt, to ensure dentists’ competencies, clinical skills should be taught and assessed accordingly. Performance assessment, including the Objective Structured Clinical Examination (OSCE), has been used globally for assessing a dental student’s stage of development for years. Many studies have concluded that by using OSCE, clinical instructors are able to understand students’ clinical competencies better than by the written examination. OSCE, lately becoming a part of Licensure examination in North America and Japan, has been widely recognized as an important tool for assessing clinical skills. It includes a national standardized assessment of clinical competencies such as patient-physician communication, clinical history taking and clinical examination skills.
To promote quality of dental education, School of Dentistry, National Taiwan University established an OSCE study group which works on guideline development and faculty training. Through the information collection and literature review, our comparison of the core competencies of dentistry of five countries came to similar conclusions in a number of areas; however, they varied in other areas, which may due to cultural differences. We built up the blueprint of OSCE by employing the Nominal Group Technique to identify the essential core competencies required of dental students prior to graduation. After a series of faculty training and reliability in performance assessment through mini-OSCE, the examination guideline was set up. Finally, we held the 6 stations of OSCE for 36 students from 3 different levels. The results of OSCE may help clinical faculties to formulate their teaching content and to modify their teaching skills. We also hope that the guideline we developed for the implementation of OSCE will act as a reference when dental schools perform OSCE in the future.

Keyword : Performance assessment, Objective Structured Clinical Examination, Nominal Group Technique

口試委員會審定書 i
誌謝 ii
中文摘要 iii
英文摘要 iv
第一章：導論 1
1.1 緣起 1
1.2 國內外牙醫學教育制度 3
1.3 國內外牙醫師檢定與執照核發制度 5
1.4 各國牙醫畢業生需具備之臨床核心能力 7
1.5 我國牙醫畢業生需具備之臨床核心能力在地化之考量 8
1.6 考官訓練與臨床實作評量結果之信度關係 9
第二章：研究目的 10
第三章：實驗材料與方法 12
3.1 探討各國牙醫學畢業生核心能力訂定之異同 12
3.1.1 研究對象 12
3.1.2 研究步驟 12
3.2 我國牙醫學畢業生核心能力之訂定 13
3.2.1 研究對象 13
3.2.2 研究步驟 13
3.2.3 資料分析 14
3.3 考官訓練與臨床實作評量結果之信度關係 15
3.3.1 總論 15
3.3.2 研究對象 15
3.3.3 研究步驟 15
3.3.4 資料分析 16
3.4 牙醫OSCE考試之執行 17
3.4.1 總論 17
3.4.2 研究對象 17
3.4.3 研究方法 18
3.4.4 資料分析 18
第四章：實驗結果 20
4.1 各國牙醫學畢業生核心能力訂定之異同 20
4.2 我國牙醫學畢業生核心能力之訂定 21
4.2.1 基本資料 21
4.2.2 投票結果 21
4.3 考官訓練與臨床實作評量結果之信度關係 23
4.4 牙醫OSCE之執行 24
第五章：討論 25
5.1 研究各國牙醫學畢業生核心能力訂定之異同的重要性 25
5.2 我國牙醫學畢業生核心能力之訂定 27
5.3 考官訓練與臨床實作評量結果之信度關係 29
5.4 牙醫OSCE考試之執行 31
第六章：結論 36
第七章：未來研究努力方向 38
第八章：圖目錄 39
第九章：表目錄 55
參考文獻 69
附 錄 74
附錄 I 74
附錄 II 91

1.Plasschaert A, Boyd M, Andrieu S, et al. 1.3 Development of professional competences. Eur J Dent Educ 2002;6 (Suppl 3):33-44.
2.Lin CP. The Development of Taiwan''s Dental Education, Examination System and Global Connection. Taipei: Lin CP, 2008.
3.Sanz M, Treasure E, Van Dijk W, et al. Profile of the dentist in the oral healthcare team in countries with developed economies. Eur J Dent Educ 2008;12(Suppl 1): 101–10.
4.Department of Dentistry, School of Dentistry. National Taiwan University. Goals. Taipei, Taiwan: NTU, 2014. Available at: http://dod.ntu.edu.tw/main.php?Page=N2#t02 [Date accessed: May 2, 2014]
5.The Faculty of Dentistry of the National Yang-Ming Medical College. Education. Taipei, Taiwan: NYMU, 2014. Available at: http://dod-e.web.ym.edu.tw/front/bin/ptlist.phtml?Category=2 [Date accessed: May 2, 2014]
6.School of Dentistry, National Defense Medical Center. Goals. Taipei, Taiwan: NDMC, 2014. Available at: http://www.ndmctsgh.edu.tw/editor_model/u_editor_v1.asp?id={357C8FF5-E897-4A02-89FC-246B32D2B576} [Date accessed: May 2, 2014]
7.College of Oral Medicine, Taipei Medical University. Future Development. Taipei, Taiwan: TMU, 2014. Available at: http://oral.tmu.edu.tw/intro/super_pages.php?ID=intro2 [Date accessed: May 2, 2014]
8.College of Oral Medicine, Chung Shan Medical University. Features and Future Development. Taichung, Taiwan: CSMU, 2014. Available at: http://csom.csmu.edu.tw/front/bin/ptdetail.phtml?Part=eng-SchofDent [Date accessed: May 2, 2014]
9.School of Dentistry, College of Medicine, China Medical University. Missions and Educational Objectives. Taichung, Taiwan: CUMD , 2014. Available at: http://cmud.cmu.edu.tw/english/index.php [Date accessed: May 2, 2014]
10.School of dentistry, Kaohsiung Medical University. Kaohsiung, Taiwan: KMU, 2014. Available at: http://dent.kmu.edu.tw/front/bin/ptlist.phtml?Category=8 [Date accessed: May 2, 2014]
11.ADEA Foundation Knowledge and Skills for the New General Dentist: (As approved by the 2011 ADEA House of Delegates). J Dent Educ 2013;77:903-7.
12.Cowpe J, Plasschaert A, Harzer W, Vinkka-Puhakka H, Walmsley AD. Profile and competences for the graduating European dentist – update 2009. Eur J Dent Educ 2010;14:193-202.
13.Australian Dental Council. Professional attributes and competencies of the newly qualified dentist. Australian Dental Council June 2010. Available at: http://www.ada.org.au/App_CmsLib/Media/Lib/1003/M221764_v1_634054490286100138.pdf [Date accessed: May 2, 2014]
14.Gerrow JD, Murphy HJ, Boyd MA. Review and revision of the competencies for a beginning dental practitioner in Canada. J Can Dent Asso 2007;73:157-60.
15.Dental Council of New Zealand. Competency standards and performance measures for dental therapists. DCNZ, 2012. Available at: http://www.dentalcouncil.org.nz/Documents/Policy/TherapistsCompetencyStandardsMeasures.pdf [Date accessed: May 2, 2014]
16.Yip HK, Smales RJ. Review of competency-based education in dentistry. Br Dent J 2000;189:324-6.
17.Beltr&;aacute;n-Neira RJ, Beltr&;aacute;n-Aguilar ED. Taxonomy for competency-based dental curricula. J Dent Educ 2004;68:978-84.
18.Stanley SL Tsai, CH Chen, JT Fang, JJ Tsai, SC Chang, A Guideline for the Implementation of Objective Structured Clinical Examinations. J Med Educ 2008;12:52-7.
19.Barman, A., Critiques on the Objective Structured Clinical Examination. Ann Acad Med 2005;34:478-82.
20.Zartman, R.R., et al., Using OSCE-based evaluation: curricular impact over time. J Dent Educ 2002;66(12):1323-30.
21.David M. Kaufman, E., Karen V. Mann, Arno M. M. Muijtjens, Cees P. M. van der Vleuten, A Comparison of Standard-setting Procedures for an OSCE in Undergraduate Medical Education. Acad Med 2000;75(3):267-71.
22.Tamara GS, Norma MV, Yolanda RPA, Aar&;oacute;n PR, Roc&;iacute;o GD, Jer&;oacute;nimo SM. Objective structured clinical examination as an instrument for evaluation of clinical competence in pediatrics. A pilot study. Bol Med Hosp Infant Mex 2011;68(3): 169-76.
23.Hamann C, Vorkan K, Fishman MB, Silvestri RC, Simon SR, Fletcher SW. How well do second-year students learn physical diagnosis? Observational study of an objective structured clinical examination(OSCE). BMC Med Educ 2002;2(1):11.
24.Curtis DA, Lind SL, Brear S, Finzen FC. The correlation of student performance in preclinical and clinical prosthodontic assessments. J Dent Educ 2007; 71(3):365-72.
25.Cunnington JPW, Neville AJ, Norman GR. The risks of thoroughness: Reliability and validity of global ratings and checklists in an OSCE. Adv Health Sci Educ 1997;1:227-33.
26.Schoonheim-Klein M, Muijtens A, Habets L, et al. On the reliability of a dental OSCE, using SEM: effect of different days. Eur J Dent Educ 2008;12(3):131-7.
27.Liao SC, Hunt EA, Chen W. Comparison between inter-rater reliability and inter-rater agreement in performance assessment. Ann Acad Med 2010;39(8):613-8.
28.Holmboe ES, Huot SJ, Huot SJ. Effects of training in direct observation of medical residents'' clinical competence, A randomized trial. Ann Acad Intern Med 2004;140(11):874-81.
29.Cook DA, Dupras DM, Beckman TJ, Thomas KG, Pankratz VS. Effect of rater training on reliability and accuracy of mini-CEX scores: a randomized, controlled trial. J Gen Intern Med 2009;24(1):74-9.
30.McLaughlin K, Ainslie M, Coderre S, Wright B, Violato C. The effect of differential rater function over time (DRIFT) on objective structured clinical examination ratings. Med Educ 2009;43(10):989-92.
31.Tsai TC, Lin CH, Chen CL, Chao CC, Yeh TL, Tsai JJ, et al. Analysis of OSCE Results: Experience in National Cheng Kung University Medical College. J Med Educ 2006;10:313-23.
32.Abe S, Kawada E. Development of computer-based OSCE re-examination system for minimizing inter-examiner discrepancy. Bull Tokyo Dent Coll 2008;49(1):1-6.
33.Downing SM. Threats to the validity of clinical teaching assessments: what about rater error? Med Educ 2005;39(4):353-5.
34.Yang YY, Lee FY, Hsu HC, Huang CC, Chen JW, Lee WS, et al. A core competence-based objective structured clinical examination (OSCE) in evaluation of clinical performance of postgraduate year-1 (PGY(1)) residents. J Chin Med Assoc 2011;74(5):198-204.
35.Sturpe DA, Huynh D, Haines ST. Scoring objective structured clinical examinations using video monitors or video recordings. Am J Pharma Educ 2010;74(3).
36.Devitt JH, Kurrek MM, Cohen MM, et al. Testing the raters: inter-rater reliability of standardized anaesthesia simulator performance. Can J Anesth 1997;44(9):924-8.
37.Delbecq A, Van de Ven A: A group process model for problem identification and program planning. J Appl Behav Sci 1971;7:466-92.
38.Dobbie A, Rhodes M, Tysinger J, et al: Using a modified nominal group technique as a curriculum evaluation tool. Fam Med 2004;36:402-6.
39.Tsai SL, Ho MJ, Chang SC. Defining the Core Competencies of Medical Humanities Education through the Nominal Group Technique. J Med Education 2008;12:70-6.
40.台大&;#63990;床醫學&;#63956;&;#63972;委員會
http://udd.ord.ncku.edu.tw/ezfiles/78/1078/img/485/950103-1.pdf
41.Wilkinson TJ, Frampton CM, Thompson-Fawcett M, Egan T. Objectivity in objective structured clinical examinations: Checklists are no substitute for examiner commitment. Acad Med 2003;78(2):219-23.
42.Brown G, Manogue M, Martin M. The validity and reliability of an OSCE in dentistry. Eur J Dent Educ 1999;3:117-25.
43.Mossey PA, Newton JP, Stirrups DR. Scope of the OSCE in the assessment of clinical skills in dentistry. Br Dent J 2001;190:323-6.
44.Lin CJ , Chang JZC , Hsu TC , et al. Correlation of rater training and reliability in performance assessment: Experience in a school of dentistry. J Dent Sci 2013; 8(3):256-60.
45.Feudtner C, Christakis DA, Christakis NA. Do clinical clerks suffer ethical erosion? Students'' perceptions of their ethical environment and personal development. Acad Med 1994;69(8):670-9.