| 摘要: | 1. 研究背景與目的：
「神經學檢查」是一系列評估人體神經系統功能的身體檢查。利用徒手或是借助各種檢查工具，醫師藉由引發不正常的神經學檢查表徵，可以推測神經系統究竟是何處受到病變影響，做出定位診斷。遠距教學常用在醫學教育，讓學員的學習不受到時間、空間的限制，其中「同步遠距」視訊教學提供更多的師生即時互動及回饋。關於神經學檢查的同步遠距教學，目前尚未有系統性文獻回顧或統合分析的文獻，也沒有跟傳統實體教學比較的隨機對照試驗或非隨機對照試驗，只有少數個案報告。因此，本研究針對實習醫學生的神經學檢查教學，比較同步遠距視訊和傳統實體教學的成效，在知識面和操作技巧面上，是否有顯著差異，並探討其中影響的因素。
2. 研究方法：
本研究收納臺北市某大學醫學院的醫學系五年級實習醫學生（clerk 1），自2022年8月29日至2023年5月5日止，輪訓醫學中心級附屬醫院的內科及神經內科的學員，利用教學部定期常規舉辦的Basic Clinical Skills理學檢查課程中，神經學檢查課程進行研究，每梯次約8-10名學生，共6梯次，研究共8個月。以非隨機對照的準實驗設計，將實習醫學生分組，進行神經學檢查的操作教學：原實體上課學生維持在教學部的教室進行實體教學，另邀請同年級學生於教學部利用筆記型電腦透過remote clinical presence system進行同步遠距視訊學習。上課前、後，分別由學生透過客觀結構式臨床技能測驗(objective structured clinical examination, OSCE)個別對標準化病人進行肌腱反射檢查，包括二頭肌、肱橈肌、三頭肌、膝反射、踝反射，共5部位，由事先經過考官共識的神經內科醫師擔任考官，透過評核表項目，針對學生的各項表現進行評分，以評估學習成效，並請學生填寫Google問卷表單進行前、後測，評估其學習動機信念和科技接受度、神經學檢查相關知識、執行神經學檢查的自信心。進而比較同步遠距視訊學習是否不劣於教室實體教學。根據學生在課前是否曾經在神經內科輪訓和演練操作過神經學檢查的經驗、及其學習動機信念和科技接受度分組，比較是否曾經輪訓、以及演練操作的經驗多寡、及其學習動機信念和科技接受度的程度，其學習成效是否有差異。
3. 研究結果：
本研究截至2023年5月1日止，共收案57人，其中56人完成問卷和知識測驗題前、後測，結果發現同步遠距組(n=26)和實體教學組(n=30)在神經學檢查的知識面的進步程度沒有顯著差異(1.65±1.68 vs 2.31±2.14, p=0.24)，且兩組在課後都有比課前顯著進步(p<0.001)。其中55人完成肌腱反射神經學檢查OSCE前、後測，結果發現同步遠距組(n=26)和實體教學組(n=29)在課後操作肌腱反射檢查的自信心(4.19±0.94 vs 4.28±0.70, p=1.00)、和操作技巧面的進步程度(28.04±15.55 vs 23.48±9.09, p=0.22)也都沒有顯著差異，且兩組在課後都有比課前顯著進步(p<0.001)。課前曾經到神經內科輪訓者，在肌腱反射檢查OSCE前測的「步驟2：受檢者準備姿勢」(17.44±6.30 vs 13.00±5.31, p<0.05)和「步驟3：操作技巧」(10.93±4.48 vs 8.70±2.83, p<0.05)，比未曾輪訓神經內科者表現較佳。利用同步遠距視訊進行神經學檢查教學後，在肌腱反射檢查的操作技巧，學習動機信念高者會比學習動機信念低者有顯著較多的進步(34.67±13.92 vs 22.36±15.02, p<0.05)，而對於遠距學習科技產品的接受度高者會比接受度低者有顯著較多的進步(34.15±15.99 vs 21.92±12.91, p<0.05)。研究中同時發展神經學檢查知識測驗題，包括劇本一致性測驗、延伸配合題、全面整合拼圖，可評量學生應用、分析的能力；也研擬肌腱反射檢查OSCE評分表，針對5個檢查部位和4個檢查步驟，信度極優(Cronbach’s α=0.912)；另編制神經學檢查課程問卷，可在課前評量學生的學習動機信念(Cronbach’s α=0.891)和遠距學習科技產品的接受度(Cronbach’s α=0.949)。
4. 結論：
以同步遠距視訊進行神經學檢查教學的成效，在神經學檢查的知識面和肌腱反射檢查的操作技巧，與實體教學無顯著差異，顯示同步遠距學習值得推廣，特別是針對臨床技能教學的某些項目，例如肌腱反射檢查。雖然同步遠距視訊無法取代實體教學，但確實可作為輔助非同步遠距影片和實體課程的另一種教學方式。
1. Background and objective:
The "neurological examination" (NE) is a series of physical examinations to assess the function of a person's nervous system. Using bare hands or with the help of various examination tools, doctors can speculate where the nervous system is affected by the lesion by triggering abnormal neurological examination signs and make a localized diagnosis. Distance teaching is commonly used in medical education, so that students' learning is not limited by time and space. Among all, "synchronous video conferencing" provides more real-time interaction and feedback between teachers and students. Regarding synchronous distance teaching of the neurological examination, there has been no systematic review or meta-analysis, and there have been no randomized or non-randomized controlled trials comparing that with traditional physical teaching, except only a few case reports. Therefore, this study aimed at the neurological examination teaching of medical students, comparing synchronous video conferencing and traditional face-to-face teaching, to see whether there is significant difference in the teaching effectiveness in knowledge and skills, and to discuss the influencing factors.
2. Materials and methods:
This study recruited the fifth-year medical students (clerk 1) of the Department of Medicine in the College of Medicine of a certain university in Taipei from August 29, 2022 to May 5, 2023, when they rotated in the Department of Internal Medicine or Neurology of an affiliated medical center. In the Basic Clinical Skills physical examination course regularly held by the teaching department, the neurological examination course was used for research, with about 8-10 students in each batch and 6 batches in total, and the research lasted for 8 months. The medical students were assigned into groups to receive teaching of the neurological examination: the original students who attended the physical class maintained face-to-face teaching in the classroom of the teaching department in the medical center, and some other students of the same grade were invited to use the laptop computer in the teaching department to conduct synchronous distance learning through video conferencing by using the remote clinical presence system. Before and after the class, the students were requested to receive an objective structured clinical examination (OSCE) to check the tendon reflexes of a standardized patient on 5 different locations, including biceps, brachioradialis, triceps, knee reflexes, and ankle reflexes. A group of neurologists who had reached the consensus beforehand served as the assessors. Through the checklist items, the performance of the students was scored to evaluate the learning effect. The students were asked to fill out a Google questionnaire to perform pre- and post-tests to assess their learning motivational beliefs and technology acceptance, their knowledge of the neurological examination, and their confidence in performing the neurological examination. Then the researchers would compare whether synchronous distance learning with video conferencing was not inferior to face-to-face teaching in the classroom. According to whether the students had been trained in neurology before the class and had practiced the neurological examination, and according to the level of their learning motivational beliefs and technology acceptance, the researchers further analyzed whether there was a difference in their learning effectiveness.
3. Results:
As of May 1, 2023, a total of 57 participants were enrolled in this study, of which 56 completed the questionnaire and the knowledge pre-test and post-test. Comparison of the mean change scores in both groups with nonparametric statistics revealed that there was no significant difference between the synchronous distance learning group (n=26) and the traditional face-to-face teaching group (n=30) in knowledge gains (1.65±1.68 vs 2.31±2.14, p=0.24). Both groups have significantly improved after class (p<0.001). Among them, 55 people completed the OSCE pre- and post-test of the tendon reflex examinations. The synchronous distance learning group (n=26) improved as much as the traditional face-to-face teaching group (n=29) in NE skill acquisition (28.04±15.55 vs 23.48±9.09, p=0.22). Both groups have significantly improved after class (p<0.001) and showed equivalent confidence in NE performance (4.19±0.94 vs 4.28±0.70, p=1.00) after class. The participants who had been to the Department of Neurology for rotation training before this class performed better in "Step 2: Preparation" (17.44±6.30 vs 13.00±5.31, p<0.05) and "Step 3: Technique" (10.93±4.48 vs 8.70±2.83, p<0.05) of the tendon reflex OSCE than those who had not been trained in neurology. After being taught the neurological examination with synchronous video conferencing, those with high learning motivational beliefs improved significantly more in the tendon reflex examination skills than those with low learning motivational beliefs (34.67±13.92 vs 22.36±15.02, p<0.05), and those with high acceptance of distance learning technology products made significantly more progress than those with low acceptance (34.15±15.99 vs 21.92±12.91, p<0.05). In this research, a series of neurological examination knowledge tests were developed, including the script concordance test, the extended matching questions, and a comprehensive integrative puzzle, which could evaluate students' ability to apply and analyze. Also, an OSCE checklist for the tendon reflex examination skills was created, aiming at 5 different tendons and 4 different steps, with an excellent reliability (Cronbach's α=0.912). In addition, a neurological examination course questionnaire was prepared to evaluate students' learning motivational beliefs before class (Cronbach's α=0.891) and their acceptance of distance learning technology products (Cronbach's α=0.949).
4. Conclusion:
There is no significant difference between synchronous video conferencing and traditional face-to-face teaching in the teaching effectiveness of the neurological examination regarding knowledge and skills of the tendon reflex examination, which shows that synchronous distance education is worth promoting, especially for teaching clinical skills. Although synchronous video learning cannot replace in-person teaching, it can indeed be used as an alternative method to supplement asynchronous online videos and on-site courses. |
