의과대학생들 사이에서의 Peer Nomination(동료지명) 예측: 사회적 네트워크 접근법 (Acad Med, 2016)

의과대학생들 사이에서의 Peer Nomination(동료지명) 예측: 사회적 네트워크 접근법 (Acad Med, 2016)

Predicting Peer Nominations Among Medical Students: A Social Network Approach

Barret Michalec, PhD, Douglas Grbic, PhD, J. Jon Veloski, MS, Monica M. Cuddy, MA, and Frederic W. Hafferty, PhD

동료지명은 의학교육 프로세스에서 학생의 임상역량/공감/연민/휴머니즘/프로페셔널리즘 등등 여러 긍정적 특성을 평가하기 위해 자주 사용되는 도구이다. 이러한 흔한 사용이 방법의 유용성을 보여준다. 예컨대 Pohl은 최소한 한 명 이상의 동료로부터 임상 혹은 인문의학적으로 뛰어나다고 평가받은 의과대학생들은 (그렇지 않은 학생에 비해서) 교수에 의해서도 임상역량을 인정받아으며, 공감점수도 더 높았다. 비슷하게 Dannefer, McMormack, Arnold 등도 동료평가의 응답이 내적일관성과 평가자간 신뢰도를 모두 갖추었다고 말했다.

Peer evaluation is a method frequently used within medical education to assess students’ clinical competence, empathy, compassion, humanism, professionalism, and other positive attributes and abilities. The frequent use reflects the method’s utility; for example, Pohl et al1 found that medical students who had been nominated by at least one of their peers as “the best” in areas of clinical and humanistic excellence were rated significantly higher in clinical competence by faculty and reported higher empathy scores compared with those students who received no nominations from peers. Similarly, work by Dannefer et al,2 McCormack et al,3 and Arnold et al4 (among others) shows that students’ responses to peer assessment scales display strong internal consistency and interrater reliability.

동료평가의 한 방식이 동료지명이다. 이는 "각 그룹원이 스스로 특정 퍼포먼스나 역량이 뛰어나다고 생각하는 다른 그룹원을 일정 수로 지명하는 방식"이다. 기본적 전제는 동료가 서로의 능력과 행동에 대한 unique observer이므로 시험/교수의 평가/자기보고 척도를 넘어서는 가치있는 정보를 줄 수 있다는 것이다.

One facet of peer evaluation is peer nomination, with “each group member naming a certain number of group members as the best along a particular performance dimension or quality.”5 The basic premise underlying this method is that peers serve as unique observers of each other’s abilities and actions and therefore offer valuable information beyond that ascertained by exams, faculty evaluation, and self-report measures.5–7

연구의 목적은

We undertook this study to explore

• (1) what factors predict the likelihood of a student nominating another student; and

• (2) what clusters, if any, occur among peer nominations.

의과대학 내에서, 다른 여러 social institution과 마찬가지로, 개개인들은 자신과 비슷한 집단과 associate하려는 경향이 있고, 이는 사회네트워크 문헌에서는 "homophily"라고 부른다. "유유상종“birds of a feather flock together.”"과 비슷한 의미기도 하다. 이러한 관점에서, 공통적 관심/경험/관점을 공유하는 개인들이 서로서로 더 connect하려고 하며, 이에 따라 상호작용의 기회도 많아지고, 서로 강력한 사회적 유대 significant social ties를 만든다.

Within medical school, much like in any social institution, individuals tend to associate and bond with others who are similar to them, a phenomenon referred to in the social network literature as homophily—something akin to the classic adage “birds of a feather flock together.”8 From this viewpoint, individuals who share common interests, experiences, and perspectives may be more likely to seek out and connect with one another, thereby increasing their opportunities to interact and, in turn, cultivate significant social ties with one another.

따라서, homophily의 원칙에 따라, 우리는 특정 인구통계학적 특성을 공유하는 학생 혹은 비슷한 학교-단위 특성(성적, 교과목 이수, 전공선택)을 공유하는 학생들이 같은 social network 안에 있을 것이라고 가정하였다.

Therefore, and following the homophily principle, we would assume that students who share certain demographic characteristics (such as gender, race, or age) or particular school-based characteristics (such as similar class rank, accelerated program status, or specialty choice) are likely to be nested within the same social network.

방법

Method

세팅

Study setting

The Sydney Kimmel Medical College at Thomas Jefferson University is a large private medical school located in an urban setting. We conducted this study in 2013 as part of the graduation survey administered as part of the Jefferson Longitudinal Study of Medical Education.10

측정, 과정

Measurements and procedure

"당신의 전문직적&개인적 발달에 유의한 긍정적 영향을 준 동료는 누구입니까?" 이 질문은 Arnold and Stern의 동료지명에 관한 질문표본을 기반으로 만들었다.

Students were asked to think back to their medical school experiences to answer the question, “Which of your classmates had significant positive influences on your professional and personal development?” This question is representative of questions that elicit peer nominations in that, following Arnold and Stern,5 “nominations consist of each group member naming a certain number of group members as the best along a particular performance dimension or quality.”

표본

Sample

Using independent t tests and chi-square analyses, we found that these respondents were representative of the class with respect to age (P < .60), gender (P < .58), race/ ethnicity (P < .67),* membership in the accelerated program (P < .37), and specialty choice (P < .35). However, their mean scores on Step 1 (mean = 230)and Step 2 Clinical Knowledge (CK; mean = 241) of the United States Medical Licensing Examination were significantly higher (P < .001) than those of the nonrespondents’ means on Step 1 (mean = 218) and Step 2 CK (mean = 234). N

분석 전략

Analytical strategy

네트워크 밀도와 상호성을 측정함. 

At the descriptive level, we first examined network density, which is simply the proportion of all possible ties in the network that are, in fact, present. We also measured the extent of reciprocity—that is, of all pairs of students that have any tie, what percentage of these pairs have reciprocated ties, whereby student i nominates student j and vice versa.

• If the nominations occur at random, then reciprocity would equal network density.
• If reciprocity is greater than network density, then the network of nominations are likely conditioned by dependencies, such as common group membership, between pairs of students.

Relational contingency table (RCT) analysis 를 활용하여 within group와 between group의 density of ties의 차이를 분석함. 만약 "sameness"가 동료지명을 예측한다면, 이는 tie가 '집단 내'에서 더 발생할 가능성이 높음을 말한다. 따라서 RCT란 무작위로 지명했을 때에 비해서 집단-내 밀도와 집단-간 밀도의 차이가 어떻게 다른지를 보는 것이다.

We then employed relational contingency table (RCT) analysis to examine the differences in the density of ties (positive nominations) within groups versus between groups. (By “groups” we are referring to students within the same variable set—e.g., same age group, same gender, or same specialty choice.) If “sameness” predicts the presence of positive nominations, then ties will be more likely to occur within than between groups. RCT analysis therefore provides a global test of whether the within- and between-group densities differ from what we would expect if the nominations observed were randomly distributed across pairs of students (random distribution would mean that belonging to a particular group had no influence on whom one nominated).

결과

Results

학생 당 피지명된 숫자는 2~75였으며 중간값은 30이었다. 총 190명의 학생이 지명되었고, 최소 2명에서 최대 52명의 학생에게 지명을 받았다. 평균적으로 학생은 32명의 동료를 지명하였다. 네트워크의 밀도에서 dyadic connection은 0.151수준이며, 즉 모든 가능한 지명의 15.1%이 실제로 네트워크상에 존재했다. 상호성을 보면 25.3%에서 상호지명하였다. 즉 reciprocity가 density보다 높다.

The number of designations (i.e., nominations received) per student ranged from 2 to 75 with a median of 30. A total of 190 students (90%) were designated as being a positive influence by between 2 and 52 classmates. On average, students nominated 32 other students (31.7 students to be exact, with a standard deviation of 32.3). Examining the density of network of positive designations shows that the degree of dyadic connection is 0.151, or 15.1%. That is, 15.1% of all possible nominations are present within the network. An examination of reciprocated ties shows that 25.3% of all pairs of students with a tie reciprocated positive nominations. Thus, reciprocated ties occurred more often than they would have by chance, since reciprocity (0.253) is greater than density (0.151).

Table 1 provides results for the global tests of homophily. Results show a deviation of observed nominations from randomness for accelerated program (x2 = 243.97, P < .02) and specialty choice (x2 = 746.22, P < .02)

 

 

 

Table 2 shows the ratio of observed to expected nominations, derived from the RCT analysis, for the accelerated program versus nonaccelerated program groups, and for each specialty area choice group.

 

 

 

 

Table 3 shows the results from a test of whether patterns of within- and between-group ties differ across groups. For specialty choice, the probability of any one student nominating another student with a different specialty choice—that is, the probability of between-group ties—is 0.145, or 14.5%.

 

 

산부인과와 안과 학생들이 특히 집단-내 지명이 높았다. Accelerated program학생을 고려하면, 집단-간 지명의 가능성은 10.9%였다.

Ob/gyn and ophthalmology students had particularly high within-group nominations. Regarding the accelerated program students, the probability of between- group nominations is 0.109, or 10.9%.

 

 

Discussion

비록 동료지명이 성별/연령/석차를 중심으로 모이지는cluster 않았으나, accelerated six-year program에 있는 ㄱㅇ우나 특정 전공과목에 들어간 경우 서로를 더 긍정적 영향을 주는 사람으로 선택하였다.

Although peer nominations did not cluster around gender, age, or class rank, those students within an accelerated six-year program, as well as those entering certain specialties, were more likely to nominate each other as a positive influence on their professional and personal development.

accelerated six-year program에 있는 학생이 서로를 더 선택하였는데, 의학교육이 일반적으로 정서적이나 심리적 긴장과 고난을 겪는 시기라고 본다면, accelerated six-year program이 이러한 스트레스를 더 악화시키거나 더 큰 영향을 주게 만들었다고 주장할 수도 있다. 비유적으로 본다면, 전통적 교육이 오븐이라면, accelerated program 은 전자레인지이다.

We found that students within the six-year accelerated program were more likely to nominate each other than students not in the accelerated program. Although medical education in general is considered to be rife with emotional and psychological tension and hardships,13–15 it could be argued that an accelerated program may actually exacerbate and/ or accentuate the impact of those stressors, given the program’s more condensed structure. Put metaphorically, whereas a traditional medical education program could be considered an oven, an accelerated program might be considered a microwave.

Michalec and Keyes는 1학년 학생(accelerated six-year program에 있지 않은)이 학교 처음부터 끝까지 정서적 well being이 낮아지고, social well being은 높아진다. 저자들은 1학년이 집단적으로 스트레스와 긴장을 겪기 때문에, 서 서로서로를 더 편안하고 지지적으로 느끼고, 따라서 사회적 connectedness를 강화시킨다고 주장하였다. 같은 현상이 (비록 더 두드러지게 나타나지만) accelerated program에서 있을 수도 있다.

Michalec and Keyes16 found that although first-year medical students (of a nonaccelerated program) decreased in emotional well-being from the beginning to the end of the school year, they actually increased in their social well-being. The authors posit that the first- year students experienced stressors and strains together as a group (not just as individuals) and thus found comfort and support among one another, thereby fortifying their social connectedness. It is quite possible that this same phenomenon—but at an even more pronounced level—occurred among the students in the accelerated program. 

우리는 또한 학생들이 같은 전공과목 계획을 가지고 있을 때 서로를 더 많이 지명하는 것을 보았다. 특정 전공과목에서 임상 일렉티브를 하는 것이 사회적 유대감social connection을 강화하는 '기회구조'가 되는 것이다. classic social theorist인 Robert Merton,에 따르면 “Opportunity structure designates the scale and distribution of conditions that provide various probabilities for individuals and groups to achieve specific outcomes.” 이다. 유사하게 Macintyre 등도 기회구조를 "사회적 상호작용과 관계를 촉진할 수 있는 물리적/사회적 환경에서의 사회적으로 패턴화된 특징"이라 하였다.

We also found that students were more likely to nominate peers with similar specialty plans as a positive influence on their personal and professional development than to nominate students in other fields. because the clerkship electives associated with given specialty areas serve as opportunity structures to cultivate and strengthen social connections. As noted by the classic social theorist Robert Merton,17 “Opportunity structure designates the scale and distribution of conditions that provide various probabilities for individuals and groups to achieve specific outcomes.” Similarly, Macintyre et al18,19 define opportunity structures as socially patterned features nested within the physical and social environment that can facilitate social interactions and social relations.

accelerated program처럼 어떤 임상실습은 interconnectedness를 강화시켜주었는데, 그 이유는 그런 임상실습은 정서적으로 강렬한 경험이나 상호작용을 주기 때문이다(출산 등). 이들의 공통적 경험이 학생 간 유대를 강화시켜주었을 수 있다.

Much like the accelerated program, certain clerkships (e.g., ob/gyn or surgery) may intensify a sense of interconnectedness among students because such clerkships are riddled with emotionally intense and evocative experiences and interactions (e.g., participating in delivering a baby). These shared encounters may strengthen bonds between individuals, with such heightened emotionality positively influencing their social cohesion.

homophily 원칙으로 돌아와서, 유사한 흥미나 성격을 가진 학생이 비슷한 과목에 이끌리게 되고, 서로를 더 잘 찾아내는 경향이 있고, 더 자주 상호작용한다. 이러한 이유로 전공과목이란 비슷한 성향을 가진 사람을 모으는 봉화beacon이나 자석이 되는 것이다. 우리는 전공과목 선택이 사횢거 연결을 강화시켜주는 강력한 힘이며, 임상실습 그 자체가 이러한 목적을 달성할 수 있게 기회구조를 제공한다고 해석한다. 그럼에도 불구하고 학생 간 유사성이나 공통의 관심이 근본적인 메커니즘일 수 있다.

Returning to the homophily principle, it is also possible that students of similar interests and/or personalities are drawn to similar specialties,20–23 and that students of similar interests and/or personalities tend to find each other and interact more frequently. As such, specialties may serve as a beacon or magnet for like-minded individuals. We interpret our findings to suggest that specialty choice is a strong force in fostering social connections, and that clerkships themselves serve as opportunity structures to this end. Nonetheless, shared interest and likemindedness among students (that drive them to the same specialty) may be a primary causal mechanism.

사회적 네트워크는 공통의 규범/정체성/집단적 행동을 길러주고 강화시킨다. 한 연구에서 병원의 특정 과가 그 과의 고유한 문화를 보호하고 유지하고자 하며, 그러한 고립된 문화siloed culture가 과간 협진interdepartmental care delivery에 영향을 줌을 밝힌 바 있다. 우리의 연구에서 이런 과-기반의 공유된 규범/정체성/문화가 이미 의과대학4학년때 나타남을 보여준다.

Social networks nurture and encourage shared norms, identity, and collective behavior.24 Previous research has shown that specific departments within care delivery institutions (e.g., hospitals) maintain and protect their own departmental cultures (which include language, norms, and care delivery tactics) and that such siloed cultures have an impact on interdepartmental care delivery.25 Findings from our study suggest that these department-based shared norms, identity, and general cultures could manifest themselves as early as the fourth year of medical school. 

기회구조와 이번 연구를 함께 생각하면, 동료지명은 상호작용의 양과 강도에 영향을 받는다.

These findings, and the accompanying discussion of opportunity structures, suggest that peers’ selections of others may be influenced by the amount and intensity (i.e., positive contact) of interactions among and between them.

 

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Acad Med. 2016 Jun;91(6):847-52. doi: 10.1097/ACM.0000000000001079.

Predicting Peer Nominations Among Medical Students: A Social Network Approach.

Michalec B1, Grbic D, Veloski JJ, Cuddy MM, Hafferty FW.

Author information

• 1B. Michalec is associate professor, Department of Sociology, and assistant director of health research, Center for Drug & Health Studies, University of Delaware, Newark, Delaware. D. Grbic is lead research specialist, Policy Research Studies, Research and Data Programs, Association of American Medical Colleges, Washington, DC. J.J. Veloski is director of medical education research and instructor in psychiatry and human behavior, Sidney Kimmel Medical College, Thomas Jefferson University, Philadelphia, Pennsylvania. M.M. Cuddy is measurement scientist, National Board of Medical Examiners, Philadelphia, Pennsylvania. F.W. Hafferty is professor of medical education, Division of General Internal Medicine, Program in Professionalism and Values, Mayo Clinic, Rochester, Minnesota.

Abstract

PURPOSE:

Minimal attention has been paid to what factors may predict peer nomination or how peer nominations might exhibit a clustering effect. Focusing on the homophily principle that "birds of a feather flock together," and using a social network analysis approach, the authors investigated how certain student- and/or school-based factors might predict the likelihood of peer nomination, and the clusters, if any, that occur among those nominations.

METHOD:

In 2013, the Jefferson Longitudinal Study of Medical Education included a special instrument to evaluate peer nominations. A total of 211 (81%) of 260 graduating medical students from the Sidney Kimmel Medical College responded to the peer nomination question. Data were analyzed using a relational contingency table and an ANOVA density model.

RESULTS:

Although peer nominations did not cluster around gender, age, or class rank, those students within an accelerated program, as well as those entering certain specialties, were more likely to nominate each other. The authors suggest that clerkships in certain specialties, as well as the accelerated program, may provide structured opportunities for students to connect and integrate, and that these opportunities may have an impact on peer nomination. The findings suggest that social network analysis is a useful approach to examine various aspects of peer nomination processes.

CONCLUSIONS:

The authors discuss implications regarding harnessing social cohesion within clinical clerkships, the possible development of siloed departmental identity and in-group favoritism, and future research possibilities.

PMID:

 

26826072

 

DOI:

 

10.1097/ACM.0000000000001079

[PubMed - in process]