책소개2009년 실기시험이 첫 시행된 이후, 6회의 시험이 시행되었습니
다. 시험 초기 많은 논란이 있었으나 현재에 이르러 차츰 자리를 잡
기 시작하여 문제도 많이 다듬어 졌으며, 학교임상술기센터 현장 역
시 많은 발전이 있었습니다. 특히 OSCE시험은 5분내에 술기하나를
시행함에 있어서 과정이나 물품들을 많이 삭제하여, 여유시간이 늘었
습니다. 이는 시간싸움의 시험이 되지 않도록 하는 학생들의 의견과
국시원의 출제방침이라고 볼 수 있습니다.
출제되는 문제선정은 은행 보유 문제에서 무작위 선정한다고 알려
져 있으며, 각 항목별로 합격선 심의위원회에서 결정합니다. 문제별
통과기준과 총 문제수 통과기준이 있습니다. 과정이 약간 복잡하지
만, 간단하게 설명하자면 각회차별로 최소능력점수를 계산해나가면서
마지막회차시험에서 최종적으로 문제별 합격선을 결정하게 됩니다.
그리고 통과 문제 수 기준 합격선은 CPX, OSCE 각각 1문제로 설정하
여 위원회에서 합격 개수를 정하게 됩니다. 이와는 달리 합격률을 필
기시험과 비슷한 수준으로 유지한다는 말이 있었으며, 실제로 몇 년
간 합격률이 필기시험과 유사하였습니다. 이전에 시험평가목표에 대
해 의대협과 국시원장의 대화를 잠깐 살펴보면, 암기보다는 자질과
라뽀(rapport)형성능력을 평가하며, 당일회차에서 몇 명 탈락 등의 소
문은 사실이 아니라고 하였으며, 100% 합격이 가능한 시험이라 하였
습니다. 종합해보면, 위 과정을 통해 합격선이 결정되며 이 선이 대개
필기시험 합격률(92~96%)과 유사하게 설정되며, 100%에 가까운 통과
율도 가능함을 알 수 있습니다.
필자가 아는 바로는 실기 탈락자의 경우 합격기준 총점은 넘었으나,
합격기준 통과문제 개수를 넘지 못한 경우가 많았습니다. 이 말은 CPX,
OSCE에서 절반 정도(3/3 또는 2/4)씩 통과한 경우가 많은데 이렇게되
면 총점은 통과하나 개수(대개 8개 이상)를 통과 못해 탈락하는 것입니
다. 필자도 실기시험 세대라 실기시험을 준비하면서 채점기준의 모호함
등의 아직까지도 논란이 있는 실기시험과정에 의문이 많았습니다. 그래
서 1년여간 공부하고 후배들도 보면서, 전략을 짠 것은 다음과 같습니
다.
CPX의 경우 객관적인 문답과정과 신체진찰, 설명 및 교육 등 잘했
다고 생각함에도 항목 fail이 뜨는 경우가 의외로 많습니다. 이는 다
른 사람들 역시 쉽게 잘보았기에 커트라인이 높을 수도 있으며, 채점
방향 등 공개되지 않는 부분에서 문제가 된 것이기 때문에 실기시험
의 큰 불확실 변수가 됩니다. 따라서 OSCE를 완벽하게 준비하고 시
행하여 6개를 목표로 최소 5개 이상 통과할 경우 CPX 통과개수의 여
유가 생깁니다. 이를 통해 합격안정선에 들자는 전략입니다. 잘 수용
이 안되는 수험생분들도 있을 수 있지만, 공부를 하면 할수록 CPX에
대한 의문과 CPX 특성상 사람 개개인의 평소 말투, 당일 컨디션 등의
영향이 크다는 것을 알 수 있을 것입니다. 그래서 처음부터 CPX를
잘하는 학생은 이 전략과 조금 안맞을 수도 있으나, 나머지 대부분의
학생이 이 전략을 통해 국시원장이 말씀하셨던 100%합격을 했으면
하는 바람입니다. 다시 요약하자면, OSCE를 완벽히 준비하며 물론
CPX의 내용들도 빠짐없이 준비합니다. 이는 둘다 열심히 하라는 뜻
이긴 하지만, 추가로 시험일까지 남은시간이나 공부시간 분배에 있어
서 OSCE 항목 마스터를 하도록 시간 조절을 하라는 말입니다. CPX
분량이 많다보니 많은 학생들이 시간배분을 2:1 또는 3:1 이상으로
하여, OSCE를 소홀히 하는 것을 쉽게 볼 수 있습니다. 하지만 이는
매우 불안한 방법으로, 시험당일 컨디션이나 합격 기준선이 후에 설
정되는 것을 간과한 것입니다.
그러나, 몇 년간의 실기시험이 시행되었지만, CPX와는 달리 아
직 시중에는 OSCE를 공부할 만한 책이 없는게 실정입니다. 그나마
출간된 서적들은 OSCE시험과 거리가 먼 내용도 많았으며, 기존 학
장단책과 다른 내용 등으로 혼란만 가중시켰습니다. 또 실전과 다
른 내용들도 수험생들을 혼란스럽게 만들었습니다. 이런 상황에서
수험생 입장에서 마땅한 OSCE책의 부재가 아쉬웠고, 시험 및 항목
에 관해 많은 지식과 정보들을 모으고, 주위분들의 의견을 모아 이
책을 쓰게 되었습니다.
이제 실기시험의 중요성이 증가함에 따라 각 학교마다 실기시험을
내신 등에 반영하는 곳이 늘고 있습니다. 그동안 맹목적인 학장단책
따라하기와 소문이나 전수 등으로 바르지 못한 술기를 진행하는 경우
를 보았습니다. 그래서 이 책은 다른 책들의 단점을 보완하고, 여러
가지를 추가하였습니다.
1. 중요한 부분에는 일러스트 및 설명을 달았으며,
2. 시험 세팅 예시 등을 제공하여 시험 전 리마인드 및 똑같이 준
비해서 연습할 수 있게 하였고,
3. 술기 진행 중 쉽게 놓치는 부분을 정리하였으며,
4. 시험 도중 돌발상황 대처법 등을 미리 생각해보록 하였고,
5. 변형 출제가 예상되는 것에 미리 정보 등을 제공하였고,
6. 간이 체크리스트를 제공하여, 연습과정에서 평가할 수 있도록
하였습니다.
7. 항목에 관하여 알면 도움이 되는 내용을 더하였습니다.
8. 추가로, 이제 CPX 일부 항목이 된 OSCE 항목 진찰부분을 맨
뒤에 넣어 참고할 수 있게 하였습니다.
목차1부 채혈 및 주사 / 1
01 혈액 배양을 위한 채혈 ························································· 7
02 정맥혈 채혈 ········································································ 17
03 동맥혈 채혈 ········································································ 24
04 정맥 주사(정맥관 삽관) ······················································· 32
05 안전수혈술기 ······································································ 39
06 피내 주사 ·········································································· 47
07 피하 주사 ··········································································· 50
08 근육 주사 ··········································································· 56
2부 검사 수기 I / 65
09 이경 검사 ··········································································· 67
10 안저 검사 ··········································································· 75
11 시력 검사 ··········································································· 83
12 정상 분만 ··········································································· 89
13 무균 가운과 장갑 착용 ······················································· 97
목 차
3부 외과적 수기 / 103
14 봉합술 ·············································································· 107
15 창상 드레싱 ······································································ 120
16 화상 드레싱 ······································································ 126
17 국소 마취 ········································································· 132
18 농양 절개 배농술 ····························································· 138
19 뼈관절 부목 고정 ····························································· 146
4부 응급 수기 및 진찰 / 159
20 기본 심폐소생법 ······························································· 161
21 전기 제세동법 ··································································· 166
22 기관 삽관법 ······································································ 176
23 기관내 흡인 ······································································ 184
24 이물질 기도폐색 응급처치 ················································ 191
5부 검사 수기 II / 197
25 척추천자 및 뇌척수압력측정 ············································· 199
26 항문직장진찰 ···································································· 207
27 자궁경부 펴바름 검사 ······················································· 213
28 질분비물 검사 ··································································· 219
29 도뇨관 삽입 ······································································ 223
6부 기타 수기 / 231
30 혈압 측정 ········································································· 233
31 심전도 검사 ······································································ 245
32 단순 흉부 엑스선 프레젠테이션 ········································ 255
33 동의서 받기 ······································································ 264
34 환자 상태 보고 ································································· 272
7부 기타 CPX 수기 / 281
35 뇌신경 기능 검사 ····························································· 283
36 소뇌 기능 검사 ································································· 294
37 팔다리 운동/감각/반사 검사 ············································· 300
38 간이 정신상태 검사 ·························································· 311
39 목부위 진찰 ······································································ 323
40 유방 진찰 ········································································· 329
41 복부 진찰 ········································································· 338
42 심장 진찰 ········································································· 346
43 폐 진찰 ············································································· 352