B101098139 鄧肇雄 Case Western Reserve University 交換心得報告 by Sau Xiong Ang

One-month visiting at School of Medicine, Case Western Reserve University Cleveland, Ohio, United States

Block 1: Becoming a Doctor 原就讀學校、科系、年級姓名實習國家實習機構獲獎年度

臺北醫學大學醫學系四年級鄧肇雄美國凱斯西儲大學醫學院 101 學年度

Ang, Sau Xiong Taiwan Medical University 3F United Medical Building 250 Wuxing St. Taipei, R.O.C. Dear Mr. Ang:

July 08, 2013

I am writing to offer our invitation for you to participate in our School of Medicine Block One learning from Monday July 15 to August 16, 2013 at Case Western Reserve University. The Block One will encompass interactive learning that holds a fundamental understanding of population and individual health, bioethics, determinants of health, health care systems, patient-centered care and other relevant topics with focus of â&#x20AC;&#x153;Becoming a Doctorâ&#x20AC;?. You will participate in small group discussion and collaborative learning with your fellow US first year and second year medical students starting the morning of July 15. You will work with Block One Leader Dr. Heidi Gullett, MD, MPH Heidi.gullett@case.edu, Block One Co-leader Dr. Scott Frank scott.frank@case.edu and Block One Manager Ms. Catherine Kane cath@case.edu . We welcome your visit to Case Western Reserve University (CWRU), as part of the University-level Collaboration between CWRU and Taipei Medical University (TMU) with agreement signed by both University Presidents on May, 2013. Please feel free to contact me if there is any assistance you need or any question you may have.

Sincerely yours,

Ye-Fan W. Glavin, PhD Family Medicine and Community Health Case Western Reserve University 11100 Euclid Avenue Cleveland, OH 44106-5036 ye-fan.glavin@case.edu C.c. Dr. George Kikano, MD. Vice Dean of CWRU Medical School and Chair, Department of Family Medicine and Community Health

Ang’s Biography

My name is Ang Sau Xiong, a Malaysian currently furthers my medical study in Taipei Medical University (TMU). I feel so glad to be given this precious chance to study for one month in the very prestigious medical school in Case Western Reserve University. Some of my backgrounds and experiences are as below, I have just retired from the position of the Vice President of TMU Medical Students’ Association (TMU MEDSA). Over the past year, I have tried my best to coordinate and facilitate the launching of some community-based volunteer services. For instance, TMU MEDSA carried out a project so called Teddy Bear Hospital, which aimed to implement some simple but common public health issues to the kindergarteners. Other than school activities, I also involved myself wholeheartedly in the inter-medical school collaboration so called the Federation of Medical Students’ Associations, Taiwan (FMS-Taiwan) for 2 years. Finally, I was selected as the national officer of Standing Committee on Reproductive Health, including AIDS (SCORA). As the national officer, my partner and I gathered the medical students who were in charge of the related issues from 12 medical schools in Taiwan, to share among each other about the interventions and finally reach a consensus to carry out different national projects, such as the sex peer education in secondary school. I dedicated a lot of time to start the whole new “Sex Peer Education” project in Taiwan to prevent the rising of HIV infection and reduce the stigma or discrimination against People Living with HIV/AIDS (PLWHA). To always get the most updated issues concerned by medical students worldwide, I have represented FMS-Taiwan twice to participate in the General Assembly of International Federation of Medical Students’ Associations (IFMSA), which were hosted in Jakarta and Copenhagen respectively. In the conference, I joined the workshop which made me a trainer of peer educators under the collaboration of IFMSA and YPEER/UNFPA. Besides, I was offered the chance to share our national project with other country and also we could get more ideas and improvements from the comments and discussions regarding our projects. Regarding my academic performance, I have passed all my subjects in these four years of medical courses and my GPA till then is 3.99. Besides, I also won the bronze award in the Siriraj International Microbiology and Immunology Competition (SIMIC) which was held by the Mahidol University, Bangkok in March, 2013. Let’s talk about something more interesting  About my hobbies, I have been playing violin for 13 years and finally passed my Grade 8 violin examination which is certified by the Association Board of the Royal Schools of Music (ABRSM). I was the chairman of TMU String Orchestra in 2009 and played as the principal second violinist. My favourite composer is Mozart Wolfgang Amadeus which I regard him as one of the geniuses in Classical Period as he could compose something which is really joyful. Furthermore, as a medical student, I know that I have to keep myself fit and be in good health condition. Therefore, I play badminton and go to gym at least twice a week to maintain good stamina. That’s all about my brief introduction. I hope that you got to know more about me after reading this  See ya!

Ang Sau Xiong (鄧肇雄)

目次一、

緣起………………………………………………………. Page 1

二、

實習機構簡介……………………………………………. Page 1

三、

國外實習企業或機構之學習  Week 1: Population Health …………………………. Page 1  Week 2: Determinants of Health……………………. Page 5  Week 3: Health Systems……………………………... Page 8  Week 4: Patient-centered Care……………………... Page 8  Week 5: Bringing it all together…………………...... Page 13

四、

國外實習之生活體驗  社福單位及校內博物館參訪………………………… Page 14  學習之餘……………………………………………… Page 16

五、

感想與建議  綜合比較與建議………………………...……………. Page 19  心得感想…………………………………………….... Page 22

六、其他  特別感謝……………………………………………… Page 23  同行夥伴……………………………………………… Page 23  附件 1 - Pandemic Flu Exercise………………..…… Page 24  附件 2 - IQ Cases…………………………………….. Page 26  附件 3 - Health System TBL Exercise……………… Page 35

緣起六月初在開一場課程委員會的會議時，醫學系系秘立源哥過來接洽我們關於到 Case Western Reserve University 交換一個月的事。當時的我們聽見有這個難得的機會，就趕緊和父母討論是否要放棄國考到美國去交換。經過一番分析和討論之後，我和儼航的父母都覺得國考還可以再考，但這個交換機會實在太難得了，所以我們便和醫學系簽署了切結書，作為我們放棄暑假考國考的證明。在經過醫學系立源哥以及秘書室順鎔哥的協調以及安排下，我們開始對整個交換有進一步地認識，也暸解到我們這一趟行程的目的及任務。除此之外，秘書室也安排我們在離開台灣之前和推動這一次交換計劃的王懿范教授見面。她不僅協助我辦理美國簽證的事宜，還很熱心對我們敘述了一些關於 Case Western Reserve University 醫學系上課的模式。於是，我們展開了我們為期一個月在美國俄亥俄州克利夫蘭市的交換生活。

實習機構簡介 Case Western Reserve University 是位於美國俄亥俄州克里夫蘭市的一所研究性私立大學。該校是由 Case Enginering School 與 Western Reserve University 於 1967 年合併而成的，目前有文理、工程、法律、管理、醫科、牙科、護理及社會科學學院。該校已有 16 名校友及教授獲得諾貝爾獎。Case Western Reserve University 有兩個醫學院，一個主要在 University Circle 校區，另一個則在 Cleveland Clinics 院區內。醫學院目前在美國排名第 25，在俄亥俄州排名第 1。醫學院學生可選擇到校內的附設醫院 University Hospitals 或是校外的 Cleveland Clinics 去實習。Cleveland Clinics 目前是全美第四好的醫院，心臟內科則是全美國之冠。【右上圖】Case Western Reserve University 在 Euclid Avenue 的入口處。

國外實習企業或機構之學習 2013/07/16 ~ 2013/07/21 Week 1: Population Health 課程內容  Block Orientation 課程介紹 o 醫學系的課程主要都以 block system 來進行，公衛的 block 包括 biostatistics, epidemiology 等學科。進入醫院前一共有 6 個 blocks，每個 block 都整合 anatomy, histology, physiology, pathology, pharmacology 一起上。  Intro to Step Challenge 小組趣味競賽 o 算是系上老師為新生所辦的一個趣味競賽，每個新生在開學第一天被分配到一個走路計步器，在 Block 1 結束時會公佈小組以及個人的最佳成績。老師藉此機會來告訴同學們有關 Determinants of health 的概念。【右圖】同學們的上課情況。  Book Discussion 閱讀討論 o 類似北醫新生在暑假必讀以及必做的閱讀報告。該醫學系選的是『My Own Country』這本書，講述在愛滋病還無法被控制的年代醫生的掙扎以及付出。

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Anatomy 解剖課程 o Lecture 的部分由學長姐來扮演 teaching assistant 的角色，1 小組有 4 位同學，2 小組一起上課，並會被分配到 1 副 skeleton。我們無法參與他們的解剖課程，但從同學那裡得知，老師會在課前在網路上提供他們很多參考閱讀資料，他們在上課前都必須把該週解剖課的內容先複習一遍，然後再到小組裡面聽學長姐教導。我們很難想像學長姐要如何把每一個同學都教會，而且把人體的構造都淋漓精緻地交給學弟妹。但經觀察，學長姐分享的基本上都是和臨床比較相關的部分，打比方說，在北醫，解剖課程比較少強調在某個橫截面有什麼構造通過，或是食道穿過橫膈膜從胸腔到腹腔的位置是在第幾節脊椎骨等在手術上會實際用到的知識。其餘更詳細的部分則由同學在老師提供的資料裡面去鑽研以及配合大體解剖的課程來更深入的學習。因為他們的大體解剖課程從 Block 2 才開始，所以我們無法實際參與，但經詢問，他們的大體老師與學生比大約是 1 比 5。 Epidemiology 流行病學 o 一開始的流行病學，老師先提供同學們一些 Biostatistics 的概念。由於美國的醫學教育屬於學士後課程，所以大家的程度都參差不齊，同學中有已經是 MPH (Master in Public Health) 的，也有曾經在大學部修習公衛或是流行病學的，所以老師提供的都是一個比較大方向的概念。生統學的部分，如同解剖學，老師所教授的比較偏向於教會學生未來懂得如何看 paper，而不是真的要同學學會如何去操作每一個檢定，因為老師知道那並不是醫生最後需要做的事。他們的授課方式讓我覺得很務實，教會學生未來在職場上所需具備的技能才是最重要的事，如果真的有同學對生統很有興趣再自行鑽研即可。老師一直在課堂上強調『Statistical significance doesn’t have to be clinical significance』，向同學們強調未來在職場上看 paper 時所需要注意的事項。 Population Health 族群健康 o 從前我們只知道 public health 相對於醫生 one by one 看病的不同，從來沒聽過 popultion health。據老師所說，population health 是最近的一個新概念，他強調『Population health is more than public health』，討論的重點甚至包括健康的不平等以及健康的決定因子在一個族群中所扮演的角色。 Understanding Prevention 認識預防 o Prevention 是 Public Health 3P 中很重要的因素，概念和北醫所學的雷同。 Determinants of Health 健康決定因子 o 這是在北醫公衛課程中比較少特別拿出來強調的學問。我曾經在之前參加世界醫學生聯盟大會中聽到別國的醫學生在國際上拋出這個概念，當時覺得很有趣，沒想到這一次竟然可以在正式的醫學課程裡看到有這樣的一堂課。健康決定因子看起來沒怎樣，但其實這門學問在預防以及維護族群健康上扮演很重要的角色。在美國，肥胖是很大的問題，在克里夫蘭甚至可以發現路上 10 個人裡頭有至少 7 個是胖子，所以他們在課程中就大量地討論快餐或是垃圾食物如何導致他們目前疾病的分層。 Introduction to Unnatural Causes (影片) o 系所放了一系列的短片在網路上，讓同學去瀏覽，並作為考試範圍。老師希望透過學生們的自主學習，對健康決定因子有更深入的暸解。 What is public health? 公共衛生 o 概念和北醫所學雷同，不再贅述。 Evidence-based IQ 實證醫學 o IQ 是類似北醫 PBL 的小組討論模式，老師在這堂課上教同學實證醫學在小組討論中的重要性，以及灌輸他們在小組討論時報 paper 的技巧。每個星期五，會有一名學生被要求在他們的 IQ group 裡，用 5 分鐘精簡扼要地報告他們自己找的和該週教案相關的 paper，並由另一名同學評分。

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Pandemic Flu Exercise 流感大流行 (沙盤演練) o 教案詳見附件 1 - 1 (Page 23)。 o 這個沙盤演練課請來將近 20 名來自不同領域，包括醫學、護理、媒體、公衛領域的教授與專家。同學們被分成 3 大班，1 大班裡有 5 小組，1 小組裡面有 10 人，每個小組負責不同的單位，像是 Local health department (衛生局), Medical first responders (急診), Hospitals (醫院), Elected Officials (政府官員) 和 Media (媒體)。每個小組裡頭分配不同的角色讓大家 role-play，像是政府官員裡頭就會有學生扮演市長或是消防局長，媒體組就會有學生扮演主播或是記者等，大家都各司其職。 o Stage 1 - 沙盤演練的進行模式為一開始主持人先將有關全球流感大流行爆發的教案念一遍，我們那組被分配到的任務是扮演政府官員，所以有同學扮演 Police chief (總警長), Medical examiner (法醫), Mayor (市長), Law director (法務部執行長), Fire chief (消防局局長), City council member (市議會成員) 等。分配好職務後，大家會先自行製作名牌，在小組內讓大家知道你是誰，然後說出自己份內要做的事。像是總警長的身份就是要向民眾解說這一次流感大爆發的真實情況，到底是透過什麼方式傳染，讓民眾不會有 second guessing；像是市議會成員要負責大眾的精神狀態等。Role play 進行到一半，先前提到的專家會根據他那方面的專長去找扮演該角色的同學進行輔導，暸解他們當下在角色扮演目中所遇到的問題以及狀況，並提供他們意見該如何更稱職地扮演該角色。經我觀察，有些專家甚至給予長達 15 分鐘的輔導以及經驗分享。【右圖】Pandemic Flu Exercise 沙盤演練進行時的實際情況。 o Stage 2 - 接下來便是小組與小組之間的討論。政府官員如衛生局負責人就會召開記者會告知民眾目前的情況，媒體就會把一些預防的概念傳達給民眾等。甚至有同學扮演不同家的電台，透過不同的報導方式來比較及彰顯媒體在傳達正確觀念的重要性。這樣的討論模式真實地模擬了未來流感大爆發時各單位人員該如何去應對眼前難題的情境，除此之外，還可以逼同學與同學之間溝通及討論。 o Stage 3 - 扮演市長的同學也必須和總警長以及消防局局長有很好的溝通，並召開記者會接受記者門的質詢等，藉此可以訓練同學們 public speaking 和臨場反應的技巧。像是記者就會詢問問市長關於需不需要在那個時期關閉學校的問題。之後，大家再回到自己的小組內去進行整合和討論，如果有討論不出來的問題再透過網路來找尋答案。 o Stage 4 - 再次回到小組與小組間的討論，此時，不斷會有媒體報導一些 breaking news 來扮演流感大爆發時的真實情況。 o Stage 5 - 主持人再次提供大家教案的第二幕，像是這類病毒已經確定會以何種方式感染，目前的發生率和死亡率是多少，何時會有疫苗，類似哪一次的全球大流行等資訊。 o Stage 6 - 市長再次出來面對群眾，公佈關閉學校等政策。 o Stage 7 - 小組內討論屍體該要安置在什麼地方以防大規模的傳染，民眾恐慌所造成的 absenteeism (請假狀況) 如何影響經濟，民眾在經過隔離之後的心理衛生狀況， paramedics (輔助醫療) 的重要性等等。每個小組在最後必須提出最重要的 2 個 concerns 和 2 個 actions。以下為各小組所提出的 concerns,

 Local health department – Understanding risk, Minimizing spreading  Medical first responders – Protection, Communication breakdown  Hospitals – Resources, Communication among staffs  Elected Officials – Resources, Communication  Media – Ratings, Transparency o 最後本案的主持人出來 wrap up，並請了一名生物倫理的專家來分享這個教案中的 bioethical issues 有哪些，他提到 Respect the deceased wishes vs. Population risk, Distribution of scarce resource, Freedom of movement, Disruption of economy, Demand for transparency vs. Panic and Hysteria。主持人還請了一位專家來解釋實際發生流感大爆發時該採取哪些措施，他提到了 Joint information center/system ( 類似災害應變中心的概念 ) 的重要性，強調 The importance of partnership (各單位之間合作的重要性), Consistency of guidelines (政策的一貫性) 和 Preplanning and tabletop exercise (模擬及沙盤演練)。綜合感想我個人覺得這禮拜讓我印象最深刻的就是 Pandemic Flu Exercise，北醫的公衛課程只提供同學許多理論，卻不曾讓同學親自操作，甚至連 PBL 的公衛教案都讓同學們摸不著頭腦。我覺得，如果校內空間允許，醫學系可以試著效仿 Case Western Reserve University 醫學系的做法，不僅可以讓同學們深入其境暸解流感大爆發時的各種情況，暸解社會上不同領域不同角色的人在流感大爆發時所面對的困境，我想這樣一定可以讓醫生在流感大爆發時會有更多不同的社會角色，並從不同的角度去思考許多問題。此外，透過討論這樣的議題介入生物倫理的方式不會顯得格格不入或是紙上談兵，是一個可以讓同學們延伸思考的好方法。

國外實習企業或機構之學習 2013/07/22 ~ 2013/07/28 Week 2:Determinants of Health 課程內容  IQ Case: Toni Jackson o 教案內容詳見附件 2 – 1 (Page 25)。 o 醫學系一年級的學生在沒有任何基礎醫學知識的情況下要去討論這個教案，想當然耳會和北醫醫學系進行的方式不太一樣。北醫醫學系著重學生在學習完所有疾病後去進行鑑別診斷 (differential diagnosis) 的能力，而 Case Western Reserve University 醫學系的教案討論則著重於培養學生自我學習的能力。他們的做法是，第一個同學把第一段念出來，下一個同學準備在白板記錄，同學會針對該段不明白或是和 Goal 相關的部分抓出來進行討論，整個過程不準時用電腦，只可以憑自己目前所知道的知識去推論以及揣測教案中不明白的部分。每個教案大約有十個段落，而且裡頭涵蓋的不只是病人在臨床上的一些表徵，還包括了病人的 history 和他所處在社會裡頭的一些現象，是一種更貼近呈現病人教案在醫生面前的一種學習方式。除了把每一段的重點列出來以外，同學也會針對不明白的 term 把他們列出來。最後，再花大約 20 分鐘的時間把各段的重點列成 learning objectives。 o 我被分配到 IQ team 3 當 observer。每次討論的時間為 2 小時，他們通常會花 10 分鐘 check-in，50 分鐘把各段重點抓出來，10 分鐘休息，15 分鐘把剩餘段落的重點抓出來， 5 分鐘用來做 EvidenceBased IQ ， 20 分鐘把各段重點列成 learning objectives，10 分鐘 check-out。 o 10 分鐘 check-in 的部分大多拿來讓大家 ice-breaking，說說自己的週末過得如要和，10 分鐘 check-out 則拿來分享今天組內討論的情況及需要改進的部分。【右圖】我與 IQ Team 3。 o Facilitator (輔助 IQ 討論順利進行的教授) 不會參與討論，但會適時地與小組同學分享 official learning objectives。 o 幾項與北醫 PBL 不同的地方有  同學必須用 google docs 去製作一份報告，但不需交給老師。  所有的 learning objectives 都必須自己查，不能在小組內分工，因為報告時是 random 輪流的。  同學們的學習態度很好，遇到不會的字眼並不會抱怨。他們在完全沒有醫學知識背景的情況下，教案內容竟然同時出現許多跨不同科別的字眼，像是 “smelly itchy vaginal discharge”, cervical os, vaginal vault, bimanual exam, cervical motion tenderness, PCR, “Abstinence-OnlyUntil-Marriage-Program”, Tanner Stage 5, menarche 等等。可見他們的老師從一開始就已經著手計劃培養學生自我學習的能力，畢竟在畢業之後甚至是在見實習的時候要具備的不是唸書的能力，而是自我學習如何解決問題的能力。  Official learning objectives 列為考試內容之一。  Social Determinants of Health and Introduction to Health Disparities 社會健康決定因子及健康不平等 o 講述 poverty, employment, education, social status 等因素對健康的影響。其中細項的討論包括個體的收入、行為、是否犯罪、嬰兒死亡率及就醫可近性。

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o 介紹一些專有名詞，如 Gini coefficient, door-to-balloon time 來評估不同程度的健康照護。 o 我覺得 social determinants of health 的概念對醫學生來說很重要，尤其是像北醫這種注重企業社會責任的學府，更應該讓同學有這樣的概念，才能從不同的角度去思考活在某個生活環境裡，不同的衣食住行究竟會對自身的健康造成什麼樣的影響。 Introduction to Community Field Experiences 社區經驗介紹 o Case Western Reserve University 的同學在每個禮拜的某一天下午都必須到克里夫蘭市的某個社福單位去參觀。這一堂課，主授老師請來一些單位的社工來與大家分享並提醒大家到社福單位去參觀時所需注意的事項，像是每次的參訪都必須穿著白袍等。 o 與北醫醫學系不太相同的是，我們在大二蔡尚穎教授的『醫療典範與倫理實踐』課程中只會到一個社福單位去參觀，而 Case Western Reserve University 的同學則有比較多的機會可以看到不一樣的社福單位。但我們在同一個單位所花的時間比 Case Western Reserve University 同學來得長，所以我們對該單位的暸解則會來得較深。 Anatomy/Histopathology 解剖課程 o 詳見第一周課程 (Page 1)。 Epidemiology 流行病學 o 詳見第一周課程 (Page 2)。 Health Systems/Understanding Insurance 健保制度/認識保險 o 美國的健保制度真的太令人頭痛了，Medicare 和 Medicaid 就已經快把我們給搞死。 o 但令我驚訝的是，Case Western Reserve University 醫學系在健保制度的課程中不只局限於傳授他們的醫學生有關美國自身的健保制度，更為同學們安排了認識世界上三個主要健保制度的課程，分別是  英國的 Beveridge Model (Strong gatekeeper requirements, Little out of pocket)  法國的 Bismarck Model (Mix of privately and publicly owned infrastructure, Get the copays back in less than three days )  加拿大的 Universal Healthcare (No out of pocket for most services, Drugs not covered, Long waiting list) Environmental Influences on Chronic Disease 環境對慢性病的影響 o Barker hypothesis - Decreased fetal growth is strongly associated with the development of chronic disease o Nurture can in fact trump nature o Change the genotype via mediators from certain behavior Occupational Health 職業健康 o 強調 occupational injury 是 preventable 的。 o 介紹 WHACS 模式  What do you do  How do you do it  Are you concerned about any of your exposures on or off the job  Coworkers or others with similar symptoms (cluster)  Satisfied with your job? o 介紹不同種類的 hypersensitivity 

Immediate - Allergic rhinitis

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Soon - Hypersensitivity pneumonitis

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Delayed - Delayed asthma, Carpal tunnel syndrome

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Latent - Lymphoma (herbicide), Mesothelioma (asbestos), Angioma (PVC)

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Generational - Mutation

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Primary Health Care and the Patient-Centered Medical Home 基層醫療及 PCMH o Primary care 的幾個重點  Accessibility  Accountability  Integration and coordination  Sustained partnership o PCMH  Patient-centered Medical Home 是 AHRQ (Agency for Healthcare Research and Quality) 所定義的一個 model。PCMH 並不是某棟建築物或是某個機構，它是用來形容提供 primary care 的組織的一種運作模式，其中包括以下要點 (大多與以上所提及的 primary care 要點雷同)，  Comprehensive care  Patient-centered  Coordinated care  Accessible services  Quality and safety Bridges out of Poverty 探討貧窮與健康的關係 o 教授強調 “Bridges is about shifting power”。 o 這堂課其實和 social determinants of health 的概念很類似，但強調貧窮導致怎樣的生活環境，以致怎樣的生活模式以及它對健康所造成的影響。最後再來探討目前在社區裡有哪一些能夠協助貧苦人家的醫療組織與單位。

綜合感想這個禮拜讓我影響最深刻的課是有關美國健保制度的介紹，因為美國的健保制度實在太複雜太難懂了。我花了許久時間來看資料，才開始對他們的 Medicare 和 Medicaid 有一些些暸解。據同學所說，他們未來在看診時都必須針對不同病人的保險狀況來計算不同的收費機制，所以他們在求學期間就必須把他們的健保制度搞懂。另外讓我驚訝的是他們“知己知彼，百戰不殆”的學習態度，或許是因為他們的健保制度目前在一個健保改革的十字路口，所以迫使他們除了要學習自己國內的健保制度，還要暸解英國、法國和加拿大的健保制度。

國外實習企業或機構之學習 2013/07/29~ 2013/08/04 Week 3: Health Systems 課程內容  IQ: Mr. Prince o 詳見第二周課程及附件 2 – 2 (Page 27)。  Overview of the PPACA 美國健保改革簡介 o PPACA 簡稱 Obamacare，是目前醫學生一定要知道的知識。雖然還沒有定案，但教授拋出了許多問題給學生，讓他們去思考怎樣的健保制度對美國國民來說是最好的。  History of the American Health System 美國健保系統的歷史 o 這堂課有點類似我們所上的醫學史，從一開始介紹醫院的由來還有醫生在以前的社會地位，到後來講述現在美國健保制度的優點和缺點。其中也提到 Flexner, Nightingale 等人出現後對醫學教育的改變。 o 老師也提出為何美國的醫療保健支出佔 GDP 很高的百分比，health outcome 仍然很差的問題?  Anatomy/Histopathology 解剖課程 o 詳見第一周課程 (Page 1)。  Epidemiology 流行病學 o 詳見第一周課程 (Page 2)。  Accountable Care Organizations 健保合約單位 o 講述健保合約單位如何運作。 o 健保合約單位包括基層醫療、醫院、專科診所、長期照護、精神照護以及物理治療單位。 o 附設醫院負責人表示，健保合約單位目前努力的方向如下，  Improve population health  Enhance patient experience of care  Reduce and control cost of care  Process Improvement and Medical Error 醫療品質及醫療過失 o 透過介紹一個病人的案例來貫穿整堂課。 o 提出 First, do no harm 的概念。 o 教育病人 Ask me 3  What is my main problem?  What do I need to do?  Why is it important for me to do this? o Choosing Wisely 的概念，除非符合以下四個準則，否則不應該進行該項醫療措施。  Supported by evidence  Not duplicative  Free from harm  Truly necessary  Global Health 全球健康 o 首先介紹千禧年發展計劃 MDG (Millennium Development Goals)，並特別強調第四點 reduce child mortality 和第五點 improve maternal health 目前仍是全球很大的問題。 o 目前全球的 leading causes of death 包括 pneumonia, preterm birth complication, birth asphyxia, sepsis, malaria 和 diarrhea。或許這些看似在美國或台灣都不是重大問題，但全球統計下來就是如此，說明暸解 global health 的重要性，尤其是這個國際醫療扮演很重大角色的時代。 o 老師提出了一些有趣的數據例如 “90% of the patients are served by 10% of the doctors” o 老師也分享了一些他到不同國家去訓練當地基層醫師的經驗，其中包括 Laos, Kosovo, Afghanistan, Guatemala, Nepal, Vietnam 和 Northern Thailand。

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The Triple Aim and the Expanded Chronic Care Model 慢性病照護 o Triple Aim 是 2007 年提出來的概念，指的是改善  Health of a population  Experience of care  Per Capita Cost o “Act for the individual, learn for the population” o 老師強調 “For acute disease, physician is the expert; For chronic disease, patient is the expert” o 4 Principles of NUKA System  Customers drive everything  Customers must know and trust the healthcare system  Customers should face no barriers in seeking care  Employees and supporting facilities are vital to success Health Systems TBL Exercise 實際比較各國健保制度 o 詳見附件 3 - 1, 3 - 2, 3 - 3, 3 - 4 (Page 32~35)。 o 這個練習有點類似之前提及的 Pandemic Flu Exercise，也算是實際操作的課程。 o Stage 1 - 系所把大家分成 15 小組，每 5 個小組由一個主持人來說明 exercise 的規則和流程。練習一開始是請大家各自回答和健保制度以及基層醫療相關的 7 個選擇題。 o Stage 2 - 讓大家讀 4 篇不同國家健保制度的介紹，同學們必須選擇其中一篇作為自己國家的健保制度，並摘錄出其中的優缺點。 o Stage 3 - 各自選出心儀的健保制度類別後，進行小組內討論，組員們必須提出自己的看法並嘗試說服其他組員接受自己所選出的健保制度類別。最後，組內必須達成共識選出最佳的健保制度。 o Stage 4 - 主持人接著會詢問各小組的選擇並請各小組派人解釋為何會選擇那個類別的健保制度。 o 我覺得這個練習非常重要，唯有知己知彼，才能百戰百勝。透過比較不同國家的 parameter，像是 National health expenditure (NHE) 佔 GDP 的多少 %，有沒有 gatekeeping system， waiting list 要多長，國人需要繳多少的健保費，國人的 life expectancy 是多少，low birth weight (一個很重要的 index) 佔新生兒的比例的多少等參數，來暸解各國的健保制度導致該國家健康的結果為何。譬如，加拿大的健保制度雖然完善，但因為有 gatekeeping system，所以要看專科都得等 primary care physician 轉診給 specialist，而其中的 waiting time 竟然要高達 4 週。相比之下，台灣在健保制度下就沒有這個問題，但卻衍生了國人年均看診次數居高不下的情況。每個健保制度都有它的優缺點，像是在美國除了最單純的國人健康問題以外，健保制度的規劃和執行還大大地受到藥廠以及政治因素的左右，使健保制度變得不復單純。

綜合感想我對美國醫學教育實事求是的精神感到非常的敬佩，多餘的課老師不會上，太鑽研的課老師也不上，太基礎的老師也不會教，老師所教的都是學生自己學會看不太懂而且未來一定能夠在職場上用到的知識。課程的設計非常有連貫性，除了理論知識的傳授以外，系所會細心地設計各種課程來讓同學們實際去思考。雖然這看起來有點填鴨式地逼學生一定要參與討論，但現在大多的同學都是按表操課的，有好的課程設計才能讓讓學生在學習上事半功倍。這禮拜下來，讓我印象最深刻的就是他們讓學生在課堂上學習不同國家的健保制度後，再設計一個可以讓他們實際操作及思考的 TBL Exercise，他們要求同學去思考，身為一個國家的首領，你的國家目前急需 adapt 一個別國的健保制度時，你會做出什麼樣的選擇。這是繼 Pandemic flu exercise 後讓我驚豔的課程，有 lecture-based knowledge，也有 exercise-based management。相較當時我們公衛課程讓我們操作的 PBL，有關福島核災的教案，同學在小組討論裡頭分享風速如何導致輻射微粒散播的物理公式，Case Western Reserve University 這一套略勝一籌。

國外實習企業或機構之學習 2013/08/05 ~ 2013/08/11 Week 4: Patient-Centered Care 課程內容  IQ: Mrs. Sanchez o 詳見第二周課程及附件 2- 3 (Page 29)。  Chronic Illness 慢性病 o 老師首先講解 acute disease 和 chronic disease 的差別，再來列舉一些常見的慢性病以及目前這些慢性病對社會、健保制度以及醫師的影響。 o 老師用糖尿病來開場白，有稍微講解 insulin 萃取的歷史，四下內分泌系統謝安慈醫師的人文課超派得上用場，有趣又有啟示  o “A thumb pinning exercise”，老師請大家分成兩人一組，然後發出這樣的指示 “Pin your partner as many times as possible in 15 seconds. I will tell you when to start”。結果全班竟然沒有一隊超過 10 次。最後老師告訴大家，其實只要一人不動，另一人迅速地動，接著再換對方動，就可以達到最多的次數。於是老師提出了一個結論 “Sometimes we get stuck in our mental models following rules that don’t really exist” o 老師藉由以上的小遊戲來告訴大家 chronic illness model 和一般疾病的處理方式是不太一樣的。因為醫師能夠為慢性病病人做的事是少之又少的，許多來複診的慢性病病人其實當下並沒有什麼問題，大多都需要他們在看診以外佔大部分時間的情況下好好的照顧自己，培養正確的飲食以及行為模式。  Shared Medical Appointments 共同門診計劃 o 我對這堂課的概念感到非常的有興趣。Shared medical appointments 是一個全新的概念，尤其適合用在慢性病病人身上。 o 老師將這個模式定義為 “A 90-minute (Times vary by provider) physician appointment held simultaneously with 8-10 patients with a similar condition or for a routine annual wellness physical”。這個模式不僅節省了醫師與病人的時間，更透過同一個時間看診的機會讓慢性病病人可以暸解彼此，當有更有效控制自身疾病情況的 idea 在病人當中出現時，很容易就會影響到其他的病人。同儕之間互相學習與影響的效果是不容忽視的。 o 老師最後引用了一個棒球好手的一句話 “The way a team plays as a whole determines its success. You may have the greatest bunch of individual stars in the world, but if they don’t play together, the club won't be worth a dime.”  Centering Pregnancy and Parenting 孕婦共同照護計劃 o 美國雖然 NHE 很高，但嬰兒和小孩的死亡率還是居高不下，於是醫界提出了 centering pregnancy 的概念，包括以下 13 個要點，主要就是以 group 的方式來照顧及輔導孕婦如何帶小孩，和之前提到的 Shared Medical Appointments (SMA) 有異曲同工之妙，  Health assessment occurs within the group space  Participants are involved in self-care activities  A facilitative leadership style is used  The group is conducted in circle  Each session has an overall plan  Attention is given to the core content, although emphasis may vary  There is stability of group leadership  Group conduct honors the contribution of each member  The composition of the group is stable, not rigid  Group size is optimal to promote the success  Involvement of support people is optional

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 Opportunity for socializing with the group is provided  There is ongoing evaluation of outcomes o 成效非常明顯，例如用母乳哺乳、媽媽之間的溝通的頻率都有提升，有助於改善媽媽的精神狀態及延長嬰兒的壽命。 Better Health Greater Cleveland 更好的克里夫蘭健康計劃 o Better Health Greater Cleveland 是縣政府推行的一個計劃，目的在於改善基層醫療以及降低慢性病對社會所帶來的不便及壞處，最終使命在於 “to help make northeast Ohio a healthier place to live and a better place to do business” o 老師將重點擺在病例電子化後能夠更全面地暸解整個區域的健康狀況及進行接下來的政策與措施。 o 老師也介紹了 Choosing Wisely Campaign，一個教導醫師做對病人做有效處置的運動，老師提出一些例子希望激發同學們思考做了以下的醫療處置對病人是否有好處，  Imaging for lower back pain  Neurological imaging for headaches without red flags  Cardiac imaging for patients with low cardiovascular risk  Imaging and antibiotics in acute sinusitis  Pap smears for certain age groups / circumstances o 老師也分享了以前宣傳小朋友感冒了要使用 aspirin 的廣告以及 Dr. Semmelweis 在 Vienna General Hospital 提出醫生的手是導致孕婦感染最主要來源時所受到的歧視及排擠等狀況，要同學們時時刻刻提醒自己千萬不能 resistant to change in medicine。 Anatomy/Histopathology 解剖課程 o 詳見第一周課程 (Page 1)。 Epidemiology 流行病學 o 詳見第一周課程 (Page 2)。 Health Disparities Research 健康不平等研究 o 老師首先定義何為 health disparity，即是 Non-random differences in health-related outcomes by race, gender, socioeconomic status, or other subgrouping。 o 提出的例子有  Black have 2.4 times higher mortality rates than whites.  Women with kidney diseases are 30% less likely to receive a transplant.  Poors are 1.8 times more likely to be hospitalized for bacterial pneumonia. o 老師把造就 health disparity 的因子分為 upstream 和 downstream factors,  Upstream (Influence likelihood of getting disease)  Poverty  Segregated neighborhoods  Industrial pollutants  Downstream (Influence outcome of diseases)  Health insurance  Proximity of providers  Cultural competency o 最後老師講述幾個學生主導的健康不平等研究，鼓勵更多學生往這方面去努力，  Why blacks, women, poor don’t receive kidney transplants  How physicians lobby member of Congress  Internet ciprofloxacin sales following anthrax outbreak  Economic and health consequences of selling a kidney

綜合感想這是最後一個禮拜的主要課程，我對老師們提出的一些心得觀念感到很有興趣，像是 Shared Medical Appointments 和 Centering Pregnancy，都是在台灣不曾聽過的 new term。這兩個新觀念的共同點都是在醫病關係中減少醫師的角色，把焦點放回到病人身上，實際地去執行 patient-centered care，透過病人和病人身為同儕之間的 collaboration，來對自己的病情或是育嬰狀態有實質上的經驗分享，除了改善病人的疾病狀態，也同時改善了病人的心理狀態。老師們並不會覺得這還是一個新的概念，就有所保留地不分享給學生，我對老師們願意分享新觀念以從學生的反應中互惠學習得到回饋的做法感到非常敬佩。

國外實習企業或機構之學習 2013/08/12 ~ 2013/08/16 Week 5: Bringing it all together 課程內容  IQ: Jack Lee o 詳見第二周課程及附件 2 – 4 (Page 31)。  Step Challenge Awards 趣味競賽頒獎 o 這是在第一周提到系說辦給同學們的團隊趣味競賽活動，老師借助頒獎的機會向同學們再次強調 social determinants of health 的概念，透過群體運動的效果，希望同學們可以暸解他們辦這項活動的意義。【右圖】Step Challenge Awards 頒獎。  Epidemiology 流行病學 o 詳見第一周課程 (Page 2)。  Exam 考試 o 我們無法實際參與他們的考試，但據同學分享，他們的考試一共分為兩天，第一天考解剖，第二天考其餘的課。 o 他們的考試以 subjective questions 為主，一共考 5 個小時。我覺得北醫以 MCQ 考題為主的模式除了讓同學可以靠考古題輕鬆過關以外，也無法訓練出學生完整解釋一個概念的技巧。就如同他們在 IQ 討論的時候一樣，學生在討論過程中是不允許用電腦的，就算是他負責講解的 learning objectives 也一樣，都必須早已經在腦裡先組織一次，再把概念說出來.透過這樣的練習，知識才能真正地地烙印在腦海裡。綜合感想 Case Western Reserve University 考試的評分就和許多國外的大學一樣，學生不會知道自己考獲的實際分數，他們得到的只是一個分數的 range，像是 distinction, merit, credit, passed 或 fail。我覺得這樣的評分方式不僅是用來避免同學彼此之間為了些許分數惡性競爭的辦法，也是適應 subjective question 評分的一個方法 (只要言之有物，就應該過關)。雖然批改 subjective questions 相對來說需要較多的人力，但我覺得不能因為這樣而將二年級以後幾乎所有的考試都以 MCQ 以及電腦閱卷來取代。希望校方慎重考慮整合 subjective questions 和用 range 來考核的評分機制，以和國際接軌，並期待藉此培養出更有競爭力的醫學生。

國外實習之生活體驗社福單位及校內博物館參訪 Department of Family Medicine , University Hospitals 參訪由於先前不知道要有 vaccination record 才能到當地的社福單位參訪，所以我們錯失了這一次和同學們一起參與 field experience 的機會。但經過 Block 1 主授老師 Dr. Heidi Gullett 的協助與安排下，我們有機會到 Case Western Reserve University 的附設醫院 University Hospitals 的家醫科參訪。接洽我們的醫生花了將近 20 分鐘的時間與我們分享美國的健保制度，我們也適時地反映了台灣的健保制度讓她暸解。接下來的 1 個小時半，她帶著我們在家醫科內的診間參觀。家醫科的走廊以及儲藏室裡有許多的紙本病例，經了解，他們最近才開始規劃以電子病歷來取代過去的紙本病例，目前還在努力建檔中。另一個新奇的事是，有一個診間裡擺放著一台翻譯機，透過和外界連線的服務，當醫生遇到無法使用英語或醫生熟練的語言進行溝通的病人時，這台機器就扮演很重要的角色。除此之外，我們也和該醫生聊到看診時間以及病人數的問題，她告訴我們醫生平均會在每一個病人身上花至少 20 分鐘以上的時間，一個早上要看的病人也可能只有十來個，和台灣的情況非常不一樣。透過這一次的參訪，我對美國的健保制度以及醫院的健康照護有了更深一層的認識。與台灣的健保制度比較，台灣的病人其實還是相對幸福得多，至少以就醫的可近性以及費用來說就比美國好太多了，唯衍生的一些問題例如就醫頻率過高或是醫生服務時數過長等問題還有待醫界一同來共同解決。【上圖】University Hospitals 發給我們的參訪證件。 Care Alliance Health Center 參訪我們原本的計劃是希望可以到 Case Western Reserve University 醫學院在執行的一家 Free Clinic 去參觀。但由於時間安排上的不允許，王懿范教授幫我們安排到了另一個類似的基層醫療診所 – Care Alliance Health Center 去參觀。先來說說 Free Clinic，它的組成非常有趣，所有的行政事務都由醫學系學生來執行，而醫師只負責看病的程序，而且是義務的。隨著 Free Clinic 的壯大，以目前醫師的人力來說，已經無法再招收新病人，所以目前主要以照護慢性病患者為主要服務目的。回到主題，Care Alliance Health Center 坐落在 Cleveland 市中心，但附近的區域卻是屬於較平窮的住宅區，所以這個基層醫療診所主要是設置來服務沒有健保補助的病人。Cleveland 雖然有幾個大的醫學中心，像是 Case Western Reserve University 的附設醫院和 Cleveland Clinics 以及縣立 Metrohealth Medical Center，但住在附近的民眾要是沒有健保，還是無法到這些大型的醫學中心去就診，於是像 Care Alliance Health Center 這種基層醫療診所對他們來說就非常重要。這個診所除了一般的門診，也提供牙醫服務，每星期五也有針對女性的心靈健康服務 (如關懷受暴婦女)，甚至像無家可歸的民眾提供醫療服務。他們目前服務的對像中有 94%是美國政府定義屬於貧困的族群，有 67%是無家可歸的病患。負責人還透漏出其實這個診所的財務狀況目前一直以來都不是很好，但所幸最近開始有一些財團以及政府的支助才開始好轉。他們這樣的服務理念讓我非常的敬佩，希望這顆種子可以埋藏在我心中很久，未來也可以成為一個為弱勢病人奉獻的醫師。【右圖】我們與 Care Alliance Health Center 解說員之合照。

Allen Memorial Medical Library and Dittrick Museum of Medical History 參訪這是一個很有趣的經驗，我的 IQ Group 教授 Dr. Peter Whitehouse 請他的同事帶我們到 Case Western Reserve University 校園裡的一個附設醫學博物館去參觀。依稀記得我之前到 Mahidol University 去比賽的時候，他們的醫學博物館還分為解剖醫學博物館和寄生蟲醫學博物館，真的非常令人大吃一驚。這一次去參訪的博物館沒有那麼震撼，但也算是令人大開眼界，裡頭有一個以性健康為主題的展間，展示著從以前鼓勵生育的概念到現在避孕概念的演進、保險套、子宮內避孕器的發展等。另外，還展示了 1930 年代醫生辦公室、舊式顯微鏡、鐵肺、舊式 X 光機、舊式 EKG 機器等推動醫學發展不可或缺的功臣。比起歐美許多大學，北醫雖然不是一所很古老的學府，但隨著時間演進，總有一天會變老嘛，希望未來有更多相關的文物可以被設置在校內的博物館內  【上圖】Dr. Peter Whitehouse 帶領 IQ Team 3 以及我們交換學生去參觀 Dittrick Museum of Medical History。

國外實習之生活體驗學習之餘與 American Born Taiwanese 的邂逅 Case Western Reserve University 的醫學系新生組成蠻有趣的，全班約 150 人，亞洲人佔了 25%，黑人大約 3 名。開學的第三天，突然有個亞洲人過來和我們打招呼，一陣寒暄之後才發現原來他是在美國出生的台灣裔學生 – Stevephen Hung。我一直對在歐美地區長大的華人小孩有很多的疑問，像是經我在班上觀察就發現，其實亞洲小孩還是比較常和亞洲小孩坐著一起上課，能夠和白人打成一片的其實並不多。在和 Stevephen 聊天之前，我一直以為無法打成一片的原因是因為語言，但像 Stevephen 是完全在美國出生、長大和受教育的小孩，語言怎麼可能會是問題呢。聽他一番解釋之後才暸解，原來這不純粹是語言的問題，更決定性的因素是文化以及家庭教育的不同。在克里夫蘭的日子，多虧有 Stevephen 的協助，我們才得以到許多沒有車子無法到達的地方。除了出遊，Stevephen 也和我們分享許多有關他以前在念大學時的生活以及 Case Western Reserve University 在美國的知名度等當地人才會知道的一些事。Stevephen 之前在 Maryland 念大學，之後來 Case Western Reserve University 念的是 MD, PhD Program，學費是全免的，但是必須在八年之後才能畢業。在離開之際，我們還煮了一些中國菜給他和另外一位韓國裔的學生 - Joseph 吃。希望在不久的將來還有機會到美國探望 Stevephen 並重溫我們這個夏天的回憶。【上圖 1】我與 Stevephen Hung 之合照。【上圖 2】我們臨別前的聚餐。

感謝 Taiwanese Students’ Association, Case Western Reserve University 協助雖然一開始陽明大學同學聯絡 Case Western Reserve University 台灣同學會時沒有很成功，但是當我們在大學內聯絡上一名學姐 - Janice 後，我們在克里夫蘭的生活頓時變得超級豐富  她安排我們與許多學長姐見面，一起去動物園，一起去看棒球，還一起去體驗當地的文化。真的非常感謝台灣同學會在克里夫蘭對我們的照顧，這讓我想起僑生在北醫也是一樣，大家之間的感情都很好，時常相約一起渡過在國外的佳節等活動。希望我們在未來的日子裡可以在台灣相見，一同細數這夏天的美好。【右上圖】台灣學生會帶我們去吃飯及看棒球。

與台北榮民總醫院家醫科主任黃信彰先生及其夫人傳統醫學科主任陳方佩女士聚餐陽明大學教授兼台北榮民總醫院家醫科主任黃信彰先生及其夫人陳方佩主任到 Case Western Reserve University 醫學系造訪約 7 天。黃主任及其夫人在那幾天對我們的照顧不會比陽明大學學生來得少，他們非常侃侃而談，與我們分享了許多人生經驗談，還提醒我們在上課時要有好的學習態度。【右圖】與黃信彰主任及其夫人陳方佩主任攝於 Case Western Reserve University 醫學系教室外。

與王懿范教授出遊與王懿范教授第一次見面是在秘書室順鎔哥和醫學系立源哥的協調下在北醫相見。王教授回到美國與我們聯絡上之後和我們聊了許多，還安排我們和 Case Western Reserve University 醫學院副院長 Dr. George Kikano 見面。我們在那短短的 30 分鐘內受益良多，體會到了副院長辦學的熱忱和創新的思維及理念。王教授除了安排我們更認識 Case Western Reserve University 的行程以外，她也安排我們和目前在 Ohio State University 醫學院進行研究的 73 級陽明學長 Dr. Joseph 及其夫人 Mrs. Jennifer 吃飯，還聽說 Dr. Joseph 一行人在 12 月也會造訪北醫  學長與我們分享了長期旅居美國的生活還有對未來生活的規劃及打算。這讓還在求學的我們對未來有更多的憧憬，也因為站在巨人的肩膀上，讓我們更勇敢地去做夢，希望有朝一日可以實現自己的夢想。此外，王教授對我們真的照顧有加，他除了安排一些聚餐及之前提及的 Care Alliance Health Center 參訪行程外，還帶我們到北美最令人稱謂的尼加拉瀑布 (Niagara Falls) 去，旅途中我們還認識了王教授的女兒。從與王教授的交談之中，不難發現她真的是一個在工作上溫文儒雅、行事得體的女強人，在家人面前則是一個賢良淑德的好媽媽，和學生相處時甚至可稱得上良師益友，完全沒有教授與學生之間的階級觀念，非常侃侃而談。在這次的交換計劃中能夠認識王教授，我真的受益良多，希望我能夠牢記王教授與我們分享的人生哲理和人生經驗談，在我們求醫的過程中對我們造成一定程度的影響。【上圖】王懿范教授帶我們到美加邊境 – 尼加拉大瀑布去參觀。

與王懿范教授、Dr. Joseph 與夫人聚餐這是一場讓我受益良多的聚餐，感謝王懿范教授的邀約，我們才得以和 73 級畢業自陽明醫學院，且是當時著名陽明八重唱團員之一的 Dr. Joseph 和其夫人吃飯。Dr. Joseph 在飯桌上與我們談了許多他當年升上主治醫師之後，仍決定到美國去做研究的過程和心境。Dr. Joseph 先前在杜克大學服務，近幾年則隨其院長到 Ohio State University 醫學院服務。Dr. Joseph 除了和我們談他的過去，也談到了他對未來的規劃。透過這頓晚飯，我暸解到長期旅居在外的學者的一些想法，像 Dr. Joseph 憑著當初陽明十字軍的初衷，最後還是希望回到台灣來服務。王懿范教授和 Dr. Joseph 也在飯桌上和我們提起了閻雲校長，這讓我對閻雲校長從美國那麼優渥的工作環境回到自己的母校北醫服務的決定更加地敬佩。【上圖】王懿范教授安排我們與 Dr. Joseph 及其夫人聚餐。

與 Dr. Peter Whitehouse 聚餐 Dr. Peter Whitehouse 是我 IQ 組的指導老師，雖然我們交換學生在 IQ 討論小組內都只是 observer 的身份，但他對我的照顧並沒有因此而減少，他總是幫我爭取發言的機會並詢問我在台灣的經驗和一些想法。在我離開 Case Western Reserve University 之前，Dr. Peter Whitehouse 還邀我一起吃午餐，他詢問了北醫以及 Case Western Reserve University 之間的合作關係以及這一次交換計劃的目的等問題。我也向他分享了許多台灣醫療情況目前面對的問題，像是健保給付以及醫師過勞等和美國醫療不太一樣的現況。從這頓飯中，我從 Dr. Peter Whitehouse 身上學習了很多，像是普遍上美國的教授和學生之間是沒有任何 hierarchy 的觀念的，因為他們覺得未來都會是同事，而且學生思考的角度和教授思考的角度截然不同，一定可以在各自的身上學習到些什麼。這是我從小到大第一次有教授單獨約我吃飯，也是第一次有教授詢問我關於那麼多為什麼要到台灣求學，覺得台灣和美國甚至和馬來西亞的文化對醫療情況有什麼樣的影響等問題，不難發現美國教授普遍上都非常重視學生的意見。Dr. Peter Whitehouse 是一名非常有教學與臨床經驗的神經內科醫師，目前和北京大學醫學院的神經研究中心合作，他也向我表示大陸近年來在醫學院校合作的表現上非常的積極，他也希望有朝一日可以到台灣來看看  【右上圖】我於 IQ Team 3 Facilitator – Dr. Peter Whitehouse 聚餐。

感想與建議綜合比較與建議 Taipei Medical University 醫學系與 Case Western Reserve University 醫學系之比較 Taipei Medical University Case Western Reserve University 醫學系醫學系 General Background 7+1 / 6+2 (Undergraduate + PGY) 課程年數學生人數一屆大約 165 人  MD, PhD 部分獲得獎學金

4 (Graduate School) 一屆大約 150 人  MD, PhD 一共 8 年，學費全免  亦提供對外科有興趣之同學 Master in Anatomy 學位  亦提供對基層醫療有興趣之同學 Master in Public Health 學位  以 Subjective questions (Essay questions) 為主  以級數來評核 (Distinction, Merit, Credit, Passed, Fail)

學位

考核模式

 

以 Multiple choice question (MCQ) 為主以實際分數來評核

Block regarding Public Health 不屬於 block system，時數約 35 小時，第一個 block，名為『How to be a physician』，時數約課程內容包括 40 小時，課程內容包括  History and Introduction of Public Health  Public Health  Taiwanese Insurance System  Population Health  Epidemiology  Insurance System Worldwide  Communicable Diseases  Primary care  Health Inequity  Social determinants of Health  Occupational Health  Biostatistics 公衛課程  Environmental Health  Epidemiology  Long-Term Care  Chronic Illness Model  Pollution  Sharing Medical Appointments & Centering Pregnancy  Evidence Based Medicine  Health Disparity  Policy Analysis in Public Health Risk Management and Communication in Environmental Policy  Global Health  Occupational Health  Environmental Health  Evidence Based Medicine

公衛沙盤演練課程

無

認識健保制度只局限於認識台灣健保制度，附加二代健保。生物統計學需要學會如何做各項檢定。 Gross anatomy / Dissection Lecture 上課方式

大堂課，約 165 人

1: 20 大體老師/學生比 Lecture 和 Dissection 上課模兩階段 (先上 lecture，下一個學期再上 dissection) 式 PBL Discussion / IQ Discussion PBL / IQ Discussion 4 小時每月時數  以 differential diagnosis 為主 (教案不提供最後診斷)  分成 3 幕，1 幕約 1 段  學生一次看一幕 PBL / IQ  大多已經是學生已經在該 block 學習過的字眼及疾病 Discussion 形式  有些組別可以分擔及分配 minor issues  Learning objectives 不列入考試培養讀論文的習慣  口頭鼓勵及訓練讀論文的能力 Patient-Physician Relationship 二年級上學期【醫學典範與倫理實踐】課程社區經驗 1 學期共 12 小時 Communication 無 workshops

 Pandemic Flu Exercise  Health System TBL Exercise 探討世界三大健保制度，英國、加拿大、法國。只需會判別未來 paper 常見的幾項檢定是否有效。小堂課，4 人 1 組，2 小組會分配一位學長姐當 teaching assistant (TA)。 1: 5 同時進行

24 小時 (每週一、三、五各 2 小時)       

以綜合面向討論為主 (教案會提供最後診斷) 不分幕，1 幕約 10 段學生不能一次看完全部教案，需一段一段討論許多學生還沒學過的字眼，包括疾病、病人的背景及所牽涉的社福單位大家必須查所有 minor issues 並輪流報告系所會提供 official learning objectives ( 大約 10 個)，屬於考試題目範圍。(陽明大學亦是如此) 每星期需有一位同學在 PBL 小組內選一篇與教案其中一項 minor issue 相關的論文，用 5 分鐘時間報告給同學聽，並安排另一位同學評分。

每週 5 小時每週 2 小時，4 人 1 組，1 組有 1 名模擬病人。參加 workshop 時必須穿著白袍。

以上，我針對不同的面向比較臺北醫學大學醫學系和 Case Western Reserve University 醫學系的不同之處，身為一名即將邁入五年級的醫學生，  我個人認為目前最需要改變的是考核和評分機制，MCQ 的考試模式會抹殺學生唸書的動力以及降低學生的競爭力；此外，用分數來評分的機制也會導致一些沒必要的競爭，讓大學生的求學目的變了調。  再來是重新檢視每一份 PBL 教案能夠帶給學生的實質效益，我覺得大部分的教案都寫得很好，但如果有些科目本來就不太適合用北醫 PBL 的形式 (以 differential diagnosis 為目的) 來進行，是否可以考慮採用 Case Western Reserve University 的 Pandemic Flu Exercise 或是 Health care System TBL Exercise 的方式來進行  我相信透過這種沙盤演練，在某種程度上一定能夠為學生帶來更大的影響及震撼。  陽明大學的 PBL 教案內容最後會列入考試內容，和 Case Western Reserve University 醫學系的做法一樣，或許這樣能讓同學更重視 PBL 討論。  PBL 討論的分數應列入 block 的評分，我覺得系上沒有必要為了懲罰不認真 PBL 的同學而特別把學分給獨立出來，PBL 本來就是用來訓練及增進學生獨立思考以及團隊解決問題技巧的一個課程，實在沒有必要因為學生不想這樣做而選擇當他並重修，如果該學生本來就不重視 PBL，重修也只是在老師面前逢場作戲，那樣還是達不到最終效果。在目前系上考古題紛飛的時代，block 制度要是少了 PBL 分數，根本就只端看一位學生有沒有拿到考古題或是考古題背得熟不熟而已，相比在有涵括 PBL 分數的情況下，多少能分出學生在 PBL 討論上所付出努力的程度。  Case Western Reserve University 醫學系系上的老師大多在醫院都有其他職務，他們不太能接受老師只負責教學而不做任何研究。這在台灣似乎不是太普遍的情況，同學們一般的觀念還是停留在教得好的老師就應該留下，做不做研究沒關係。但這和目前北醫的政策不太一樣，所以學生和系所甚至校方的期待是有落差的。我對這個部分沒有任何的立場，唯希望校方的政策需要想辦法傳達給每一位同學知道，否則同學還是會一再地因為教得好的老師沒有做研究被解僱而感到不滿。

感想與建議心得感想時光飛逝，想當初立源哥一開始和我們說有這個計劃的時候，我們趕緊就上網搜尋 Case Western Reserve University 的資料，知道它在 Cleveland 有很有名的附設醫院 University Hospitals 和 Cleveland Clinics 之後，就超希望可以參與這個交換計劃。當然，因為先前的計劃是在暑假考國考，所以我們也花了一些時間和父母商量並詢問一些朋友的意見，才決定要前往美國進行一個月的交換。不得不說我在這一個月的日子遇到太多貴人了，從一開始在校內獲得的協助到在美國遇見的好人，都成就了我這個完美的夏天。我非常感謝校方及順鎔哥、立源哥、慧毓姐等人的協助，才得以很順利地在幾天內將辦理簽證、訂購機票等事宜處理完畢，並順利前往美國。這是我人生中第一次到美國，而且還可以到那麼有名的醫學院去進行交換，實在是我畢生的榮幸。在美國，除了受到當地教授的協助以及幫忙，更令人難忘的是旅美台灣人的熱情。雖然我不是台灣人，但托寶島的福，我受到了許許多多的照顧，也因此讓一些友情微妙地萌芽，希望我們在美國遇見的台灣人有朝一日回台灣時，可以聚首回憶這個夏天的美好。在美國的這一個月，我在課堂上學習到了很多，或許因為是學士後課程，課程的設計顯得比較重點化。像是醫學系的課表當中就不會出現一些 general education 課程，而且像之前提及的生物統計學以及流行病學都是以非常重點化的方式來教授學生未來在行醫的過程中必須具備的技能，多餘有興趣的再自行鑽研。這樣言簡意賅的課程設計，搭配美國學生自主學習及習慣提問的背景，創造在學習上的優勢。在 Case Western Reserve University，除了一般的大堂課外，他們的課程還包括了許多的沙盤演練以及實際操作課程。我覺得這是在亞洲填鴨式教育下比較少見的，只有身歷其中才會暸解那種實際操作的練習能夠為學生帶了什麼樣的後續影響。除此之外，他們一個禮拜 6 小時的小組討論課程更是讓人覺得很佩服，雖然這看起來會造就學生很大的課業壓力，但院方就是希望藉此培養學生自己求知的能力，因為在未來沒有老師的日子裡，我們還是得靠自己來找尋知識，讓自己進步。因此，這一趟旅程下來，我很慶幸自己有這個機會可以在美國那麼棒的醫學院待一個月，學習他們和台灣截然不同的課程設計。除此之外，這也是我第一次在國外 (除了台灣) 待那麼長的時間，學習如何與夥伴相處、合作準備食物、自己用手洗衣服等生活小事，都必須自行打理，自己感覺也在無形中成長了一些。【右圖】我們到宿舍附近的超商 Daves Market 去採買食材，並自行準備晚餐。

醫學這條路很長，我相信，這一個月在 Case Western Reserve University 所學的一定已經對我造成一定程度的影響，希望我能將所學實踐在我未來求學的過程當中，也希望校方如果覺得我所提出的建議是富有建設性的，能夠在未來的日子裡稍微改變並套用在北醫醫學系的課程之中。最後，我覺得這一趟行程對我真的造成非常大的影響，在未來的日子裡，如果學校的經費足夠，希望校方一樣可以推薦學生參與 Case Western Reserve University 醫學系的這項交換計劃。在此提醒前往交換的同學要記得備好自己英文版的 vaccination record，這樣才能更完整地記錄該醫學系的社區服務的範疇。相信經過積年累月的合作與交換，一定可以檢視自己的不足並逐漸將他人的優點學習起來，讓北醫的醫學課程可以更紮實及活用。

其他特別感謝臺北醫學大學簽訂兩校合作計劃臺北醫學大學國際事務處補助部分機票費用臺北醫學大學醫學院補助部分機票費用臺北醫學大學醫學系補助部分食宿費用臺北醫學大學 Senior Scholar 王懿范教授 (Professor Ye-Fan Glavin Wang) 洽談此項交換計劃及協助辦理簽證事宜臺北醫學大學醫學系陳立源先生協助洽談此項交換計劃臺北醫學大學秘書室劉順鎔先生協助洽談此項交換計劃臺北醫學大學學務處生活輔導組陳慧毓小姐協助辦理重入境事宜台北榮民總醫院家醫科主任黃信彰先生台北榮民總醫院傳統醫學科主任陳方佩女士 Case Western Reserve University 醫學院副院長 Dr. George Kikano Case Western Reserve University 醫學系 Block 1 主授老師 Dr. Heidi Gullett Case Western Reserve University 醫學系 Block 1 系秘 Ms. Catherine Case Western Reserve University 醫學系 Block 1 系秘 Ms. Denise Case Western Reserve University 醫學系 Block 1 IQ group 3 指導教授 Mr. Peter Whitehouse Case Western Reserve University 台灣同學會 Ohio State University 研究教授 Dr. Joseph 及夫人 Mrs. Jennifer Overlook Villa 房東 Mrs. Lucy 和 Mr. Charlie 同行夥伴臺北醫學大學簽醫學系五年級吳儼航同學國立陽明大學醫學系四年級蘇家睿同學國立陽明大學醫學系四年級張瓊文同學

附件 1 - 1 Pandemic Influenza Tabletop Exercise Block 1, 2013 Introduction: The purpose of this exercise is to give participants an opportunity to experience the extent and complexity of issues related to a pandemic flu emergency. Preparation for and response to public health emergencies represents one of the most important intersections between the US medical care and public health systems. Addressed in this exercise will include US health systems issues, historical precedent, the role of different stakeholder groups, the values of incident command systems, the biology of novel infectious agents, and the anticipated toll of such an event. When: The Block 1 Pandemic Influenza Tabletop Exercise will take place on Friday, July 19 from 8:00 to 1:00.

What: This “Tabletop exercise” will simulate the process of planning for and responding to Pandemic Influenza. The initial component of the session will take place with the whole class. The session will start with a whole class session to provide background information about public health emergencies and pandemic influenza. The Class will be divided into 4 different learning groups of approximately 42 students. Within each learning group, students will function in 5 IQ groups of 8 to 9 students each. Each IQ group will be assigned one of five stakeholder role: 1) Local health department; 2) Medical First Responders: Emergency Medicine (including EMS) and Primary Care; 3) Hospitals (including Infectious Disease specialists and Intensivists); 4) Elected officials; 5) Media. Each group will receive instructions about the role they are to play during the tabletop exercise. Some groups will have more than one role within the stakeholder group. An initial scenario will be introduced to the whole class, who will then move to the 4 separate learning groups. From this point, these learning groups will operate independently, with each of the four groups supervised by a public health emergency expert. Each group will work through the same scenario, with injects offering more information released intermittently through the session. Each Stakeholder group will be given unique information at the beginning of the exercise and at each inject that is important to all Stakeholder groups, but only available through communication with other Stakeholder groups. Schedule: 8:00 to 8:10 Introduction, Ground Rules, Schedule 8:10 to 8:30

“It’s Coming” Learning Objectives 1. Describe the scenario of the debut of a novel virus outside of the US. 2. Discuss the complexity of a systematic response to public health emergencies. 3. Review pandemic knowledge, attitudes and practice of tabletop participants.

8:30 to 9:10

Transmission of Novel Virus in Humans Learning Objectives 1. 2. 3. 4.

9:10 to 9:30

Define “novel virus”. Discuss lessons from the 1918 influenza epidemic for novel viruses today. Describe pharmacological approaches to treatment of viral illness. Review antigenic drift and shift and their potential impact on future novel virus activities.

An Overview of the Public Health Emergency Response System Learning Objectives 1. Describe the incident command system approach to pandemic response. 2. Introduce the language of public health emergency response. 3. Describe action planning tasks and process.

9:45 to 10:00 Transition to medium sized groups/break

9:45 to 12:15 Action Plan Learning Groups: Responding to Public Health Emergencies 9:45 to 10:15 Within Stakeholder Group Discussion: Students read about their role then discuss it within the group in the context of the current scenario Learning Objective 

Discuss the stakeholder role(s) assigned to your IQ group in the scenario (see Learning Objectives for Stakeholders)

10:15 to 11:00 Between Stakeholder Group Discussion Communicate between groups about what information is needed from each other to mount an effective response to the changing scenario Learning Objective 

Analyze and react to the scenario regarding the changing nature of the public health emergency based on your stakeholder role

11:00 to 11:30 Between Stakeholder Group Discussion: Second information inject Communicate between groups about what information is needed from each other to mount an effective response to the changing scenario Learning Objective 

Analyze and react to injects regarding the changing nature of the public health emergency

11:30 to 12:00 Within Stakeholder Group Discussion: Synthesis of final lists of concerns and actions Learning Objectives  

List the top 3 concerns that your stakeholder group holds regarding this public health emergency (i.e., delivery of vaccine or prophylaxis to home bound). List the top 3 specific actions your stakeholder group would recommend to cope with or mitigate the impact of the epidemic (i.e., create a priority list of recipients of limited resources—vaccine or antiviral medications) .

12:00 to 12:30With Incident command leadership, as a whole group   

Share 2 concerns and 2 actions with the whole group (each group) This should create a list of top 10 concerns and actions. What is missing? Describe the top 3 bioethical dilemmas raised during the epidemic exercise

12:30 to 1:00 Hot Wash—Large Group Debrief and Expert Feedback Debrief in place with your medium sized group Learning Objectives: 1. Discuss how your view of the emergency response was changed or informed by the various stakeholders in the exercise 2. Describe something that surprised you during the exercise 3. Discuss the most important interactions between the medical care and public health systems 4. Describe volunteer training and opportunities available to health science students

附件 2 – 1 Block 1: Becoming a Doctor Week 2: Determinants of Health IQ Case 1 Toni Jackson STUDENT VERSION

GOAL To understand that treating STIs in Cleveland teens extends beyond treating the individual patient to advocating for change in socioeconomic factors in the community. To understand the medical aspects of sexually transmitted infection (STI) in Cleveland teens including the epidemiology of transmission, diagnosis, treatment, prevention, and bioethical issues. To also understand the impact of social determinants of health including social & educational environment, physical environment, and health services. __________________________________________________________________________________________ LEARNING OBJECTIVES 1. To be released 26-July 2013. __________________________________________________________________________________________ CASE VIGNETTE Toni Jackson is a 15 year-old girl who comes to the Free Clinic of Greater Cleveland without her parent for a routine adolescent visit. She is the youngest of four children of a single mother. She has no concerns that she shares with the doctor on initial questioning. Toni says that she does not use tobacco or alcohol, but does say that she has “experimented with marijuana” and that her friends “get high.” She says she is not “sexually active,” but has friends who are. Menarche occurred at 9 years of age. Menses occur regularly every 30 days with 5 days of moderate flow. She describes moderate menstrual cramps, worse with her last period. She complains of a “smelly, itchy” vaginal discharge of one month duration. She was advised by her older sister to “take a douche” and not worry. She has no medication allergies. On further questioning, she acknowledges that she has had sex, but is not “active” like her friend who has multiple partners and daily intercourse. She has had 3 sexual partners during the past year, and is currently in a monogamous relationship for the past 3 months with a 17 year-old male. She states that she uses condoms “every time,” but upon questioning explained that she does not use the condoms for the full duration of intercourse. She has not noticed any penile discharge in her partner and he has not mentioned pain or burning with urination. The doctor explains to Toni that she will need to do a pelvic examination. Toni relates that this is her first pelvic exam and that she is very nervous. Friends have described the pelvic exam as “torture.” The doctor used a pelvic model and speculum to show Toni how the exam is done.

On physical exam, Toni is a healthy appearing 15 year-old girl. Pubertal development is Tanner Stage 5. Following active efforts to reassure Toni, the doctor carefully inserts a small-sized speculum in Toni’s vagina. There is a profuse green-yellow discharge in the vaginal vault. The doctor inserts two swabs into the cervical os, one for a “wet prep” and the other to send for PCR testing. The cervix appears “friable.” On bimanual exam, there is equivocal cervical motion tenderness and it is difficult to determine whether the patient’s discomfort is a result of the palpation of the uterus and adnexa or a result of her discomfort with the procedure itself. Microscopic evaluation of the wet prep reveals many WBC’s and many motile, flagellated organisms. Urine pregnancy test is negative. One of the swabs of the cervix is sent for PCR testing. Further urine and blood tests are sent. Toni is treated with metronidazole for trichomonas vaginitis and instructed to inform her sexual partner of the infection. She is told that further testing for sexually transmitted diseases will take about a week for results, and a return visit is scheduled. It is recommended that her partner come to the Free Clinic as soon as possible for testing himself. She is referred for HIV counseling and agrees to undergo HIV testing. One week later, test results reveal: ● ● ● ● ● ●

Chlamydia trachomatis: positive Neisseria gonorrhea: positive Syphilis IgG: positive Reflex RPR: positive HIV antibody test: negative Hepatitis B surface antigen: negative

You meet with Toni for a follow-up appointment at the Free Clinic to inform her of the results of her tests and to treat the infections. She states that she is not going to tell her sexual partner because she “is never going to speak with him again.” She is concerned that her mother not find out about the infections. When you begin to discuss the need for protection against HIV, sexually transmitted infection and unintended pregnancy, Toni says, “I’m never having sex again.” You ask her to tell you about the sex education program at her school (an Abstinence-Only-Until-Marriage Program). She said she was told that condoms didn’t work and had no instruction about effective condom use. You use the remainder of the clinical encounter counseling Toni about how to use condoms and about prevention of HIV and sexually transmitted infections. You also review the range of contraceptive options that are available to prevent pregnancy. As a volunteer physician at the Free Clinic, you are concerned regarding the number of adolescents—both male and female—presenting with sexually transmitted infections. You are aware of a recent report by the Cleveland Department of Public Health on the increase in incidence of sexually transmitted infections (including syphilis) in the community. You are concerned about the rate of sexual activity among youth in the Cleveland area and about sexual education in area schools. You review local data to inform your approach to clinical practice and community intervention. You are asked to advise your school board on how to handle the subject.

附件 2 - 2 Block 1: Becoming A Doctor Week 3: Understanding Health Systems IQ Case 2 Mr. Prince STUDENT VERSION

GOAL To understand the basic concepts of medical error, the steps involved in investigating a medical error, and the importance of the process of quality improvement. __________________________________________________________________________________________ LEARNING OBJECTIVES 1. To be released 2-August 2013.

__________________________________________________________________________________________ CASE VIGNETTE Mr. Prince is a 51-year-old man with diabetes and multiple complications including severe peripheral vascular disease who went to his internist with intolerable pain in the right leg. On examination, both legs were cold to the touch and had open sores. Mr. Prince had no pulses in either of his legs. He was referred to a well-trained, experienced, and highly regarded vascular surgeon, who agreed to perform an amputation of the right leg for relief of symptoms. The vascular surgeon’s administrative assistant scheduled Mr. Prince’s surgery. The operation was officially but incorrectly listed as a left leg amputation. Mr. Prince was admitted to the hospital for surgery. A floor nurse noticed on her copy of the surgical schedule that Mr. Prince was scheduled for a left leg amputation, which she knew was incorrect. She called to inform the surgical nurse that surgery was incorrectly identified on the schedule. She intended to report this as a “near miss” but got busy and forgot. The surgical nurse corrected the computer-generated form. The usual protocol would be for her to go into the operating room and correct the blackboard and schedule in the operating room. This was not done. A nursing shift change occurred a few hours later. The corrected procedure was neither discussed by the nurses as they changed shifts nor was the corrected information transferred onto the official electronic schedule. The operating room had a blackboard as well as the official electronic operating schedule. Both incorrectly listed the procedure as a left leg amputation. The consent process was completed and a consent form was signed by Mr. Prince that properly identified the right leg as the amputation site. The consent process was managed by an intern (PGY-1 or post-graduate year 1, also known as a first year resident) on the surgical team who was not scheduled to be in the operating room or directly involved in the surgical procedure.

Shortly before the procedure, a technician arrived to set up the equipment, including the leg holder. Seeing the operation listed both on the blackboard and on the official schedule as a left leg amputation, he set up the leg holder on the left side of the table. Just before his surgery, Mr. Prince told the circulating room nurse that his right leg was the correct amputation site. She noted this in the hospital record and prepped the left leg for surgery. Upon entering the operating room, the surgeon reviewed the incorrect blackboard information and the incorrect surgical schedule. The team wanted to work quickly so they dispensed with the usual “time out” to check that all was well, and a left leg amputation was begun. During the procedure, a nurse reviewing the medical record saw that it indicated that surgery was scheduled for the right leg. She realized that the wrong leg was being amputated and told the surgeon, but the amputation had passed the stage of reversal and was completed. She could see that the operating room team was devastated. She thought to herself, “this is not because of any one personal error. This is a really tragic swiss cheese systems error.” The surgeon huddled with the OR team immediately after the procedure was finished and asked that they not discuss the incident until he had a chance to discuss it with the hospital administration. He was very upset and called the hospital risk management office to ask for help in planning the disclosure discussion with Mr. Prince and his family. The risk management group sent a team to meet with the Surgeon and the OR team, and the Chief Medical Officer of the hospital immediately convened a group to do an analysis of what happened based on the AHRQ categories of medical error. They also recommend employing the PDSA model in creating a systems improvement plan for the surgical suite. Your IQ group is asked to participate and instructed to address the following three questions:  What would you advise the surgeon to say to the patient and family?  How would you approach the investigation of the event?  What quality improvement plan would you propose?

附件 2 - 3 Block 1: Becoming a Doctor Week 4: Patient-Centered Care IQ Case 3: Mrs. Sanchez STUDENT VERSION

GOAL To learn about the changing prevalence of diabetes; to describe how social, cultural, and behavioral factors (determinants of health) influence the prevention and management of diabetes; and to consider the impact of health care coverage on health outcomes. __________________________________________________________________________________________ LEARNING OBJECTIVES 1. To be released 9-August 2013. __________________________________________________________________________________________ CASE VIGNETTE Mrs. Luz Sanchez is a 39 year old Mexican American woman and mother of two children. She works part-time and her husband’s job does not provide any healthcare coverage. She gets medical care at a neighborhood safety net health center. Dr. Novice who is new to the clinic and committed to its mission speaks limited Spanish. She is, however, able to understand the general story that Mrs. Sanchez is telling her. She understands that Mrs. Sanchez has fatigue and frequent urination (polyuria), blurry vision and tingling in her feet. Mrs. Sanchez tells Dr. Novice that she is worried that she has diabetes. She has a family history of diabetes and both of her children weighed more than nine pounds at birth. Mrs. Sanchez speaks limited English. She lives with her husband and her two teenage daughters. She does not smoke. She works 16 hours per week at a sedentary clerical/administrative job. Because she works part-time she is not eligible for health care coverage. Her husband is self-employed and does not have health insurance. Mrs. Sanchez’s primary physical activity is a daily, 20-minute walk with her dog. Following a recent shooting in the neighborhood she has been afraid to walk outdoors often. The Sanchez family lives in a low income area with limited public transportation. The nearest shopping center is three miles away. Dr. Novice does a physical examination of Mrs. Sanchez. General: Obese woman who appears comfortable Vital Signs: Height = 5' 4" Weight = 200 pounds BMI = 34.2 Blood Pressure = 146/88 (elevated) HEENT(Head Ears Eyes Nose Throat)- fundoscopic examination shows retinal hemorrhages RESP (Respiratory)- Clear to auscultation CV (Cardiovascular)- regular rate and rhythm, no murmurs Abdomen- No enlargement of liver or spleen detected; soft, non-tender, no masses MS (Musculoskeletal)- foot examination shows no sores Neuro (Neurological) - diminished sensation to light touch in the feet using monofilament nylon

Dr. Novice tells Mrs. Sanchez that she agrees that diabetes is a concern. She asks Mrs. Sanchez to get blood tests. In addition, she suggests that Mrs. Sanchez have her next appointments with Dr. Clement who speaks Spanish. Dr. Novice explains to Mrs. Sanchez that she has enjoyed the chance to meet her but wants to be sure that she has the opportunity to be with a doctor that she understands easily. Mrs. Sanchez thanks Dr. Novice and agrees that it would be better for her to have a doctor who is fluent in Spanish. Laboratory Values (Fasting) Blood glucose: fasting 155mg/dl (normal < 100 mg/dl) Hemoglobin A1C 9.2% (normal < 5.7%) Mrs. Sanchez returns to the clinic to see Dr. Clement. He explains in Spanish that she has diabetes and that it has already started to damage parts of her body. He counsels her thoroughly about diabetes and the need for behavioral change. He recommends that she start exercising daily and modifying her diet to lose 50 pounds. He gave her diet guidelines and a calorie counter. Dr. Clement checks the clinicâ&#x20AC;&#x2122;s supply closet and finds free samples of Actos (Pioglitazone),which he gives Mrs. Sanchez to take once a day. In addition he gives her a prescription for this medication. When Mrs. Sanchez got home, she told her daughters that she has diabetes. Her daughters told her that they had several classmates with the same type of diabetes. In addition, the school was talking about getting rid of the soda machine in the cafeteria. Mrs. Sanchez tried to follow the diet guideines Dr. Clement gave her, but found it very difficult. She took the medication until the samples ran out. When she went to the pharmacy with the prescription she discovered the price would be around $250 a month which was much more than she could afford. She regained the10 pounds she lost and her symptoms of fatigue got worse. A few months later Mr. Sanchez found a new job with a company that provided family healthcare and medication coverage. Mrs. Sanchez saw a new primary care provider that worked with an interprofessional diabetes healthcare team as part of a Patient-Centered Medical Home. She met with a dietician and a certified diabetes educator to learn about what she could do to manage her diabetes and was able to attend a few diabetes education classes. She was given a machine to check her blood sugars and a log book to keep track. She had regular follow-up appointments with the diabetes nurse specialist. The primary care physician prescribed metformin. Six months later, Mrs. Sanchez felt much better. She had lost 10 pounds and managed to keep it off. Her Hemoglobin A1C was now 7.1%. Her blood sugars ranged from 80120 mg/dl. She is worried about being able to keep up the efforts. Special Notes to Students for Friday IQ Discussion: 1. Please relate your field experience observations to this case. Consider your personal Google+ field experience post or those of your IQ team members in your answer. 2. IQ student leader: Please review your IQ teamâ&#x20AC;&#x2122;s Google+ reflection blog in preparation for the Friday IQ session and prepare several discussion prompts based on common threads throughout the responses. Please also ensure protected time during the Friday IQ session for this component of the discussion.

附件 2 - 4 Block 1: Becoming a Doctor Week 5: Preventive Care IQ Case 4: Jack Lee STUDENT VERSION

GOAL To understand the differences between prevention, screening and diagnosis in the context of a doctorpatient visit. To understand the roles of psychosocial screening, diagnosis, and treatment of alcohol dependence in primary care. __________________________________________________________________________________________ LEARNING OBJECTIVES To be released 16-August 2013. __________________________________________________________________________________________ CASE VIGNETTE Jack Lee is a 50 year old white man presenting to the office of Dr. Park, a primary care provider, for a complete physical exam. This is Mr. Lee’s first visit to Dr. Park, but his wife has been seen by Dr. Park for many years. When asked why he came in for this exam, he states that his wife scheduled the appointment for a preventive health screen because he “hit the big five-oh.” He goes on to say, “All my friends are getting colonoscopies but I’m not sure I really want that. I am really not sure why it is necessary – except as a way for doctors to make more money!” Dr. Park is not sure what Mr. Lee’s agenda is for this visit and whether or not he will be interested in health promotion recommendations. Dr. Park says, “Mr. Lee, tell me about your general health and any medical concerns you might have.” Mr. Lee does not endorse any medical concerns when asked in this open-ended fashion. He has not seen a physician outside of the emergency department since high school. (Note: He has health insurance). He has never been hospitalized but relates “3 or 4” emergency visits resulting from injuries including several lacerations, a broken finger, a broken ankle, and a broken wrist. He pronounces himself “clumsy.” Dr. Park goes through a review of systems and finds that Mr. Lee has symptoms of gastroesophageal reflux (worse at night), dyspnea on exertion (1 flight of stairs), a chronic cough, nocturia twice nightly, and increasing erectile dysfunction. He does not endorse chest pain, snoring, or dysuria. Mr. Lee is a salesman and reports no occupational exposures. He has a 40 pack-year history of smoking and is currently smoking a pack and a half per day. He states that he uses alcohol socially. When asked, “Well, how social are you?” He responds with a laugh, “Pretty social.” He states that he does not use marijuana or other drugs. He relates getting little exercise and admits concern regarding weight gain (BMI 38).

He states that he is monogamous, has been married for 20 years and has 2 children, who are now 17 and 14 years old. He relates recent stress at work and with his 17 year old daughter. His family history is remarkable for hypertension (father), diabetes (mother), and colon cancer (father). He confides that his father was a smoker and an alcoholic. As his wifeâ&#x20AC;&#x2122;s primary care physician, you are already aware that she began treatment for depression several years ago. Mr. Lee and his wife are both employed. Because of increasing employee costs for health insurance, Mr. and Mrs. Lee each chose high deductible healthcare plans. They must each pay $1500 of medical costs before their healthcare plans begin paying for a portion of any services, for prevention or treatment. After they meet their deductibles, they still have to pay 20% of the cost of medical care. Once they have paid a total of $3000 out of pocket per person (deductible and 20% portions), their healthcare plans will pay 100% of subsequent costs for the remainder of the calendar year. Though they have to pay more out of pocket if they need medical care, they have less deducted from their paychecks each month. Physical examination. General: An obese man in no acute distress. Vital signs: blood pressure of 156/100 and a pulse of 80. HEENT (head, eyes, ears, nose, throat): head atraumatic; pupils equally round and reactive to light and accommodation; tympanic membranes pearly gray with normal landmarks; nasal mucosa non-edematous; pharynx without erythema Neck exam: no anterior or posterior lymph nodes palpable; thyroid normal in size. Respiratory: breath sounds clear to auscultation; no wheezes or rhonchi heard. Cardiovascular: regular rate and rhythm. No murmurs. Abdominal exam: liver enlarged with a non-tender edge. Genitourinary exam: prostate moderately enlarged but symmetrical, smooth and without nodules. Testicular exam: small soft testes Neurological exam: intact strength, sensation and gait. Musculoskeletal exam: joints non-tender; muscle strength 5/5 bilaterally. Extremities: no pedal edema Following the completion of the physical exam, Dr. Park develops a plan to begin addressing problems he thinks are most concerning. He discusses the most common barriers to proceeding with screening colonoscopy and gives Mr. Lee a pamphlet to read. He asks Mr. Lee to think about having this test. Mr. Lee asks Dr. Park how much a colonoscopy would cost. He has not yet met the limit of his high deductible healthcare plan. Dr. Park is not sure of the cost of colonoscopy but thinks it is probably about $1000. He wonders if he will need to answer that kind of question under the Affordable Care Act. At a visit two weeks later, Mr. Lee has had an exercise stress test (on the treadmill) that is negative for ischemia (blockages in heart arteries); a chest x-ray (CXR) to evaluate his shortness of breath going up stairs and chronic cough that showed hyperinflation consistent with chronic obstructive pulmonary disease (COPD); normal lipid panel; a normal fasting glucose and hemoglobin A1C; elevated liver enzymes, and a low testosterone level. At the end of the first visit, Dr. Park asked Mr. Lee to think about scheduling a colonoscopy and gave him a pamphlet to read. Mr. Leeâ&#x20AC;&#x2122;s wife called the office and said that her husband decided to have a colonoscopy, though it will be an expense they had not planned on. A colonoscopy has been scheduled but is not yet done.

Test Cholesterol-fasting Glucose-fasting AST ALT Testosterone – 8am

Value 160 mg/dL 92 mg/dL 180 U/L 88 U/L 168 ng/dL

Normal < 180 mg/dL < 100 mg/dL <35 U/L < 35 U/L > 200 ng/dL

Dr. Park sees Mr. Lee back in the office. Mr. Lee’s blood pressure remains elevated and today is 167/98. Dr. Park explains to Mr. Lee that he has high blood pressure, an enlarged liver and blood tests that show liver inflammation and low male hormones. He says, “The way this seems to fit together for me is to wonder if you drink too much and if the alcohol is hurting your body. I’d like to ask you for a little more information.” Further questioning reveals a CAGE questionnaire positive on 3 of 4 questions (Cut down:  has tried to cut down, but efforts have always been short lived; Annoyed:  is tired of his wife nagging him about his drinking. She has enough problems of her own; Guilty:  feels guilty about the influence of his alcohol use on his daughter’s drinking; Eye-opener: negative, denies drinking in the morning to steady his nerves or deal with a hangover). He has an AUDIT-C score of 10 (drinks on 6 or more days per week, 5 to 6 drinks per day, near daily episodes of 6 or more). Mr. Lee also states that the problems he is having with his daughter involve her recent onset of underage binge drinking. His work problems “might” be related to his alcohol use. He also acknowledges that his episodes of “clumsiness” were related to alcohol use. He relates that his wife has been “nagging me for years” about his drinking. His original appointment was made because his wife threatened divorce if he didn’t get help after he went on a 2-week binge (10-12 drinks per day) following a failed attempt at a work promotion. He states that he doesn’t really feel the effect of the alcohol until after 3 or 4 drinks. The longest he recalls going without alcohol is 3 days, “to prove to my wife that I don’t need it.” He recalls feeling anxious, irritable, and “shaky” a few days after stopping alcohol. When asked whether he thinks he is an alcoholic, he relates, “I don’t drink like my father did.” His father died of complications of his alcohol dependence. He relates that he “tried cutting down” on his alcohol use, but “didn’t have much luck.” Dr. Park takes a moment to get his thoughts together. He knows that he needs to present the diagnosis of alcohol dependence to Mr. Lee in a manner that enhances the likelihood that he will accept the diagnosis and help. Though Mr. Lee’s healthcare coverage is limited to 30 days of substance abuse treatment, Dr. Park is hopeful that this will be enough, should Mr. Lee choose this type of treatment. Above all, Dr. Park knows that he needs to partner with Mr. Lee in developing and committing to a treatment plan.

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