本教學實踐研究課程規劃為系列性，銜接上下學期的二門選修課程，教學研究過程:
a) 上學期 CB：上學期主要以建構學生的臨床基礎概念為主；先修習臨床基礎先備知識與 觀念，同時熟稔臨床專有名詞與概念。其程序如下圖；過程中導入「同儕學習」模式，
第一節課請學生依分配閱讀「病態生理學」章節，統整摘要進行口頭分享，藉以讓學 生學習疾病症狀之病態生理，建構臨床基礎
知識。第二節課由臨床醫師引領初階案例的 解析與討論，藉以學習運用學過知識，也了 解臨床實境應具備的概念。初期學生對異於 過往教學模式多所焦慮，不了解該掌握的重 點，但在現場老師即時提醒、引導之下，逐
漸寬心融入課堂討論，「問」與「答」的參與也愈熱絡。 (integrative)；c)團隊關係(relationship)；d)心智習慣(habits of mind)，其成果簡述如下:
a) 成績表現分析
從學生之期末案例書面報告評量(Table 1)可以得知，學生在在 Organization 方面，CB、
CTM 課程整體學習表現比較之 p-value = 0.004，可見於更進階的課程當中，學生於 Organization 的能力有更多的成長。此外，於 Clinical reasoning on KEY features of history, symptoms and signs (p < 0.001)、Reasoning on KEY features of physical exam. and lab data (p
< 0.001)、Proper differential diagnosis (p = 0.019)、Clinical concepts (p = 0.019)、Literature and textbook review well organized (p = 0.002)，顯示於 CB 和 CTM 兩門課程之各面向中，
學生學習表現有向上提升的趨勢，且據統計上更進一步討論之意義。
Table 1. Comparison of the final reports performance between the CB and CTM courses.
Characteristics
CB (n = 31) CTM (n = 16)
P-value Mean (SD) Mean (SD)
Organization 7.26 (0.88) 8.22 (0.98) 0.004
Clinical reasoning on KEY features of history, symptoms and signs 6.77 (0.83) 8.00 (0.98) < 0.001 Reasoning on KEY features of physical exam, and lab data 6.87 (0.83) 8.00 (0.98) < 0.001
Proper differential diagnosis 7.16 (1.11) 7.94 (0.95) 0.019
Relevant readability of the context 7.48 (0.95) 8.03 (0.91) 0.069
Clinical concepts 7.19 (0.96) 7.97 (0.99) 0.019
Discussion and summary 7.23 (0.87) 7.62 (1.22) 0.269
Literature and textbook review well organized 6.90 (0.99) 7.94 (0.95) 0.002 Tests for the strength of variances between two courses with continuous variables is Student's t-test.
另外，若對兩門課程皆參與之學生之書面報告做配對比較，顯示 Clinical reasoning on KEY features of history, symptoms and signs 於 CB 課程之整體學習表現(Mean = 6.92；SD
= 1.08)、CTM 課程整體學習學生表現(Mean = 8.00；SD = 1.13)，而兩門課程表現比較之 p-value = 0.008。另外，Reasoning on KEY features of physical exam. and lab data 面相當中，
於 CB 課程之整體學習表現(Mean = 7.00；SD = 1.00)、CTM 課程後整體學習學生表現 (Mean = 8.00；SD = 1.13)，而兩門課程表現比較之 p-value = 0.010。此外，在 Literature and textbook review well organized 於 CB 課程之整體學習表現(Mean = 7.15；SD = 1.64)、
CTM 課程後整體學習學生表現(Mean = 8.00；SD = 0.96)，而兩門課程表現比較之 p-value
= 0.036。最後，其他面向雖無出現統計上差異，但整體學生的學習表現趨勢仍呈現正向 上升。也可以看出上下學期均選修的學生在二門課的表現均高於全體的 mean 值。
從學生之案例口頭報告評量(Table 2)可以得知 Discussion and summary/ Literature review 於 CB 課程之整體學習表現(Mean = 7.80；SD = 0.60)、CTM 課程後整體學習學生 表現(Mean = 8.31；SD = 0.68)，兩門課程表現比較之 p-value = 0.021。可見於更進階的課 程當中，學生於 Discussion and summary / Literature review 的能力有更多的增進，且據統 計上的差異。此外，其他面相雖無統計上差異，但皆能看出於更進階的 CTM 課程當中，
學生有更多的能力表現。
Table 2. Comparison of oral presentation performance between the CB and CTM courses.
Characteristics CB (n = 31) CTM (n = 17)
P-value Mean (SD) Mean (SD)
Case presentation well organized 7.63 (0.75) 8.06 (0.83) 0.110
Clinical concept: pathophysiology oriented 7.77 (1.02) 7.94 (0.75) 0.544 Clinical reasoning on symptoms, signs and PE 7.67 (0.94) 7.94 (0.95) 0.396
Proper differential diagnosis 7.50 (1.06) 7.94 (0.89) 0.170
Reasoning on KEY laboratory test data 7.43 (0.62) 7.88 (0.86) 0.101 Discussion and summary / Literature review 7.80 (0.60) 8.31 (0.68) 0.021
Answering questions 7.50 (0.89) 7.56 (0.99) 0.798
Tests for the strength of variances between two courses with continuous variables is Student's t-test.
另外，針對兩門課程皆參與之學生做配對比較後，同樣在 Discussion and summary / Literature review (CB：Mean = 8.08；SD = 0.08、CTM：Mean = 8.38；SD = 0.42)在兩門課 程學習表現相比後，具統計上可比較性 (p < 0.068)。其他面向雖無統計上差別，但仍可 以觀察出學生在上下學期能力成長趨勢，而且這 13 位學生在二門課的表現均高於原全體 的 mean 值。。
b) 心理技能檢測分析
從 Table 3 可以得知在 CB 課程學生於 Existing Learning Model 面相，課程前(Mean = 0.82；SD = 0.24)、課程後(Mean = 0.99；SD = 0.56)表現，前後比較之 p-value = 0.046，具 增加趨勢。而於 Integrated Critical Thinking and Application of Clinical Concepts 面向，課 程前(Mean = 0.49；SD = 0.36)、課程後(Mean = 0.77；SD = 0.40)，其前後比較之 p-value
= 0.023，亦具有統計上可進一步探討之意義。最後，於 Self-awareness After Class，Mean
= 1.18；SD = 0.22。
Table 3. Comparison of two-time evaluations in the CB course.(臨床生化學)
Characteristics (n = 27) 1st Evaluation 2nd Evaluation P-value
Mean (SD) Mean (SD)
Existing Learning Model a 0.82 (0.24) 0.99 (0.56) 0.046
Integrated Critical Thinking and Application of Clinical Concepts b 0.49 (0.36) 0.77 (0.40) 0.023
Self-awareness After Class c - 1. 18 (0.22) -
a. The questions in 1st Evaluation (Q4-11, 13-14), in 2nd Evaluation (Q4-11, 13-14); b. The questions in 1st Evaluation (Q12, 15-27), in 2nd Evaluation (Q12, 15-26); c. The questions in 2nd Evaluation (Q28-34). Tests for the strength of variances between two-time evaluations with continuous variables is Wilcoxon signed rank test.
在 CTM 課程方面，從 Table 4 可以得知學生在 Inner Learning Motivation 於課程前 (Mean = 0.81；SD = 0.10)、課程後(Mean = 0.93；SD = 0.08)，前後比較之 p-value = 0.01，
整體平均值具增加傾向。此外，Integrated Critical Thinking and Application of Psychological Skills 之面相，課程前(Mean = -0.03；SD = 0.19)、課程後(Mean = 0.38；SD = 0.17)，其前 後比較之 p-value < 0.001，亦具有統計上可進階探討之意義。可以看到透過本課程，在多 數面相當中，學生皆於課程結束之後，都有較高的成效或心理狀態正面的提升。
Table 4. Comparison of two-time evaluations in the CTM course. (臨床思路)
Characteristics (n = 14)
1st Evaluation 2nd Evaluation
df P-value Mean (SD) Mean (SD)
Existing Learning Model a 0.28 (0.67) 0.25 (0.47) 4 0.44
Inner Learning Motivation b 0.81 (0.10) 0.93 (0.08) 8 0.01
Knowledge Reconstruction and Horizontal Application c 0.49 (0.49) 0.56 (0.26) 7 0.36 Integrated Critical Thinking and Application of
Psychological Skills d -0.03 (0.19) 0.38 (0.17) 10 < 0.001
a.The questions in 1st Evaluation (Q1-7), in 2nd Evaluation (Q3-8); b. The questions in 1st Evaluation (Q8-14, 16), in 2nd Evaluation (Q9-15, 17); c. The questions in 1st Evaluation (Q19-25, 27), the questions in 2nd Evaluation (Q19-25, 27); d. The questions in 1st Evaluation (Q28--39), the questions in 2nd Evaluation (Q28-39). Tests for the strength of variances between two-time evaluations with continuous variables is Wilcoxon signed rank test.
另外，若進一步用 ANOVA 進行 CTM 課程心理技能每一個面向之間相做比較，皆具 統計上差異(Existing Learning Model, p-value < 0.001；Inner Learning Motivation, p-value = 0.01；Knowledge Reconstruction and Horizontal Application, p-value < 0.001；Integrated Critical Thinking and Application of Psychological Skills, p-value < 0.001) 。 於 Existing Learning Model 可見課前、課後心理計量據統計上變化的子題如「我不認為同儕學習成效 較佳」(課前 Mean = 1.00、SD = 0.31；課後 Mean = 0.33、SD = 0.81；p-value = 0.01)。於 Inner Learning Motivation 課前、課後心理計量具統計上變化的子題如「無法釐清問題時，
我常主動尋求解決方式」(課前 Mean = 1.06、SD = 0.06；課後 Mean = 0.30、SD = 0.24；
p-value = 0.02)。再者，於 Knowledge Reconstruction and Horizontal Application 面向，課 前、課後心理計量之變化具觀察意義子題如「病生是內科專科才需要的基礎知識」(課前 Mean = 0.64、SD = 0.55；課後 Mean = 1.00、SD = 0.64；p-value < 0.01)。最後，於 Integrated Critical Thinking and Application of Psychological Skills 面向，課前、課後心理計量具統計 變化趨勢的子題如「我不擅將自身知識，有邏輯的與他人交流」(課前 Mean = -0.29、SD
= 0.85；課後 Mean = 0.40、SD = 0.83；p-value < 0.01)。顯示在透過整體課程的口頭報告、
主題式掃描與串聯知識脈絡等運作方式下，學生在現有學習模式以及課後學習、內在性
學習動機與自我對學習成效之定位的轉變、知識的統整概念、實際層面運用的技巧、思 signed rank test 檢測學生與專家 推理差異強度。如題組一 Q2 (Difference 0.50 至 0.30)、題組 二 Q3 (Difference 1.00 至 0.14，
p < 0.05)、題組三 Q5 (Difference 0.20 至 0.08)。可見醫學生在第
由 Wilcoxon signed rank test 檢 測推理差異強度，題組三 Q4
a) 研究結果:
根據文獻報告，case-based and coached 是臨床推理教學有效的方法(Kassirer, 2010)。
本教學實踐 CTM 課程中學生累積二十多案例的解析經驗，從學生的投入與討論的熱絡 程度，都顯示學生已能從不畏懼 case，到開始感到 approach case 的樂趣，也逐漸掌握到 臨床探討病人問題的模式。從案例口頭報告與書面報告，自 CB 到下學期的 CTM 課程學
題時，更敏銳掌握重點地聆聽與觀察，並自主學習。從學生的質性回饋:「可以學到很多 臨床的思考及相關的知識，可以從不斷 approach case 的歷程了解自己哪些部分比較不瞭 解，哪些部份需要加強，讓自己重新彙整以前所學，靈活的運用。」「這門課讓我學到剖
力求精進或做得更好。」「除了對於 case 的掌握可以更有效率外，因為這堂課大多都是同
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三、 附件(與本研究計畫相關之研究成果資料，可補充於附件，如學生評量工具、
訪談問題等等)
1. SCT test 範例(CB)
Section three: clinical concept Clinical scenario
-2: much less probable -1: less probable
0: neither less nor more probable +1: more probable
+2: much more probable
A. A 23-year-old woman with cough and fever for 1 week
If you were thinking of … And then you were to find … this hypothesis becomes ...
1. infection positive blood culture +2 +1 0 -1 -2 2. pneumonia positive sputum culture +2 +1 0 -1 -2 B. A 78-year-old man with headache and fever for 10 days
If you were thinking of … And then you find that …. … this hypothesis becomes ...
3. meningitis white blood cell count reduced +2 +1 0 -1 -2 4. infection antibiotic treatment was effective +2 +1 0 -1 -2 C. A 26-year-old woman with cough and running nose for 3 days
If you were thinking of … And then you find that …. … this hypothesis becomes ...
5. upper respiratory tract infection
white blood cell count was 13,000
(normal < 11,000/mm3) +2 +1 0 -1 -2 6. common cold her temperature was 38.3C +2 +1 0 -1 -2 7. influenza A her 3 out of 4 family members have
already been diagnosed with influenza A +2 +1 0 -1 -2
2. 案例報告工作坊成果發表海報