임상 준비에 대한 학생의 의견(Med Educ, 2005)

임상 준비에 대한 학생의 의견(Med Educ, 2005)

Students’ opinions about their preparation for clinical practice

Katinka J A H Prince,1 Henny P A Boshuizen,2 Cees P M van der Vleuten3 & Albert J J A Scherpbier4

도입

INTRODUCTION

전임상 교육은 학생들에게 임상 교육을 준비시키는 것으로되어 있지만, 의대가 이러한 면에서 성공적이지 못하다는 징조가 있습니다. 

• 래드클리프 (Radcliffe)와 레스터 (Lester)가 인터뷰 한 결과, transition periods가 스트레스의 주요 원인이라는 것이 밝혀졌습니다 .1 

• 학생들은 지식이나 기술이 충분하지 않아 환자에게 도움이되지 않아 스스로 useless하다는 느낌을 보였습니다 .1 

• Alexander와 Haldane은 또한 전임상 교육이 특히 스트레스를 많이받는 기간이라고 했다.

Although pre-clinical medical education is supposed to prepare students for clinical education, there are signs that medical schools are not entirely successful in this respect. 

• Interviews by Radcliffe and Lester with final year medical students showed that transition periods were prime causes of stress.1 

• Students described  feeling useless, unable to contribute to patient care because they had insufficient knowledge or skills .1 

• Alexander and Haldane also highlighted the transition from pre-clinical to clinical education as a particularly stressful period.2

• 또 다른 연구에 따르면, 4학년 학생의 4 분의 1은 전임상 과정에서 임상 과정으로 전환하는 데 어려움을 겪었습니다 .3 

• Firth은 정신과 환자와 이야기하는 것이 학생들 사이에서 가장 큰 스트레스를 유발했으며, 사례 발표, 개인 생활에 미치는 영향, 죽음과 고통을 다루는 것 등도 스트레스 요인이 되었다.

• Another study showed that a quarter of final year students had difficulty making the transition from pre-clinical studies to clinical work.3 

• Firth found that talking to psychiatric patients caused the greatest reported stress among students, and that presenting cases, effect on personal life, and dealing with death and suffering also led to perceived stress.4

전임상에서 임상으로의 전환을 보다 부드럽게 하는 방법으로 지식과 응용이 함께 학습 된, 실제적이고 통합된 과제의 사용이 제안되었다. 문제 기반 학습 (PBL)은 이러한 과제를 제공한다. 이러한 주장에 따르면, PBL 학생들은 전임상과정에서 임상 시험으로 쉽게 옮길 수 있어야 할 것이다.

The use of more authentic, integrated tasks, in which knowledge and application of knowledge are learned together, has been proposed as a way to make the pre-clinical)clinical transition less problematic. Problem-based learning (PBL) is said to offer such tasks. If these claims are substantiated, PBL students should be able to transfer from pre-clinical to clinical training with relative ease.

Transition의 스트레스를 완화하기 위한 대부분의 권고는 전임상 시기에 맞춰져 있다. 그러나 우리는 또한 임상 시기에 대한 노력ㄷ 필요하다. 

• Remmen et al. 임상실습에서 교육 자원이 최적으로 사용되지 않으며, 의사의 대부분이 주니어 의사에 의해 제공되고, 주로 수동적인 경험에 그치기 때문에, 의대생을 위한 좋은 학습 환경을 자동으로 제공하지 않는다는 것을 보여주었습니다 .7 

• 학생들은 코칭, 피드백 및 감독이 부족하다고 자주 지적했습니다. 

• 루비츠와 응우 엔의 연구에 따르면, 임상 로테이션에서 학생의 학대 (언어 적, 신체적, 성적 및 학업 적)의 유병률이 93.7 %로 높았으며, 학생의 ability to function 뿐만 아니라 그 medical center에서 레지던트 수련을 받고자 하는 desire에도 영향을 미쳤다.8

Most recommended measures to ease the stress of the transition focus on the pre-clinical phase. However, we might also direct our efforts at the clinical side of the divide. 

• Remmen et al. showed that clinical clerkships do not automatically provide the perfect learning environment for medical students because educational resources are not used optimally, most of the teaching is provided by junior doctors and passive experiences abound.7 

• Students frequently indicated that coaching, feedback and supervision were suboptimal. 

• In a study by Lubitz and Nguyen, the prevalence of reported abuse (verbal, physical, sexual and academic) among students in their clinical rotations was high (93.7%) and had a negative impact on both student ability to function and their desire to remain at the medical centre for residency training.8

이 글의 저자들에 의한 포커스 그룹 연구에 따르면, 임상실습 초기에 학생들이 인식 한 변화에는

• 전문직 사회화와 관련된 부정적인 경험,

• 실제 환자 문제에 대한 지식과 기술을 적용하는 데 어려움

• 다른 학습 전략을 채택 할 필요성 .9.

A focus group study by the authors of the present article showed that changes perceived by students at the beginning of the clinical clerkships included 

• negative experiences associated with professional socialisation, 

• difficulties in applying their knowledge and skills to real patient problems, and 

• the need to adopt different learning strategies.9

Professional socialisation 는 의료계의 가치와 태도에 대한 점진적 동화를 수반한다. 

• 학생들이 임상 단계에 진입하면, 갑작기 전문적 행동을 보여줄 필요가 생긴다. 

• 학생들은 오랜 근무 시간과 새롭고 매우 다른 환경에 적응해야합니다 .9 

• 무엇보다 자신에게 기대하는 바가 무엇인지 확실하지 않다.

이러한 사회화 요인들은 보슈 이젠 (Boshuizen)이 "shock of practice"의 증상 중 하나로 확인한 학생들의 학습의 위기를 설명 할 수있다.

Professional socialisation entails gradual assimilation of the values and attitudes of the medical profession. 

• The need to display accepted forms of professional conduct becomes suddenly much more urgent when students enter the clinical phase. 

• Students have to adjust to long working hours and to a new and very different environment.9 

• On top of that they are uncertain about what is expected of them. 

These socialisation factors may explain the crisis in students’ learning that Boshuizen identified as among the symptoms of the  shock of practice .10

지식과 기술에 관해서, 학생들은 그들이 항상 임상 실습에 충분히 준비되지 않았음을 느낀다. 학생들의 지식은 특정 질병과 관련된 증상을 중심으로 구성되었지만, 임상상황에서는 실제 환자가 제시하는 징후와 증상에 기초하여 진단해야했습니다. 간략하게 말하자면, 학생들은 많은 질병의 증상을 나열 할 수 있었지만 환자가 증상과 불만을 호소했을 때 진단을 내릴 수 없었습니다.

Concerning knowledge and skills, students discovered that they did not always meet the demands of clinical practice. Their knowledge was organised around symptoms associated with particular diseases, but they now had to make a diagnosis on the basis of the signs and symptoms presented by a real patient. To put it briefly, although the students were able to list the symptoms of many diseases, they were unable to generate a diagnosis when a patient presented with symptoms and complaints.

방법

METHODS

Subjects

Subjects were students at Maastricht Medical School, the Netherlands, who had recently begun their clerkship rotations. The Maastricht undergraduate curriculum offers 4 years of theory-oriented, preclinical training and 2 years of clinical clerkships. It aims to bridge the gap between theory and clinical practice by a PBL curriculum with clinical skills training in the Skillslab throughout the pre-clinical phase.14 Clerkships begin at the end of Year 4 in the departments of surgery, internal medicine and psychiatry or with an elective.

Questionnaire

We designed a written survey on the 5 categories of transition-related problems identified in the focus group study: 

• professional socialisation; 

• workload; 

• patient contact; 

• knowledge, knowledge application and skills, and 

• learning and education.

The questionnaire explored students’ recent experiences as  new  clerks in those areas. The comments of 5 senior students on clarity and readability were incorporated into the final questionnaire, which contained 95 items and took approximately 20 minutes to complete according to the students in the pilot.

Procedure

We obtained a mailing list from the dean’s office of all the students whose first clerkship rotation was scheduled in 1998 (n ¼ 126). Of these 126 students, 20 were not doing a clerkship at the time of the survey. The remaining 106 participants were sent a questionnaire, together with a letter explaining the purpose of the study and a reply-paid envelope. We tried to maximise the response by sending out a reminder letter and telephoning non-responders after 2 and 4 weeks, respectively. To enable monitoring of the response, the questionnaires had unique identity codes. The codes were removed before data entry, so that participants’ names and individual responses could not be linked to the results.

Data analysis

We calculated descriptive statistics, including proportions, means and standard deviations.

RESULTS

이행기와 사회화

Transition and professional socialisation

Although almost half of the students were nervous at the start of clerkship, most students reported being mentally ready for this phase (Table 1). 

• 준비부족, 갑작스러움
  Half of the students did not feel well prepared and 40% agreed that the transition was abrupt. 

• 자퇴 생각
  Of the students, 11.2% indicated that they had considered leaving medical school at the start of clerkship. 

• 적응 어려움
  They had difficulty adjusting to the daily routine. 

• 생각보다 나음
  Clerkship was better than expected for 71.8% of the students and 36.7% indicated that during clerkship they experienced for the first time what it was like to be a doctor. 

• 안내시간의 긍정적 효과
  Agreement was overwhelming concerning the positive effect of a good introduction and substantial with respect to the desirability of a general introduction. 

• 현재의 introduction에 만족
  Less than half the students thought the current introduction was satisfactory.

Workload

• 정신과 < 내과 < 외과
  The number of hours of clinical work was lower in psychiatry (median ¼ 40 hours, interquartile range 25–75% ¼ 35–30 hours) compared with internal medicine (median ¼ 50 hours, interquartile range ¼ 45–50) and surgery (median ¼ 50 hours, interquartile range ¼ 45–53.75) (P<0.001). 

• The number of hours for independent study showed a descending order from psychiatry to internal medicine and surgery (5, 3 and 1.5 hours of self-study, respectively) (P ¼ 0.002) (Table 2).

• 근무량이 많음
  Approximately half the students thought the hours were long, the workload heavy and the work tiring. 

• 공부시간 부족
  Nearly 75% of the students perceived a huge change in workload and thought they had insufficient time for studying.

Patient contact

• 환자 contact는 문제 없음
  For the majority of the students, patient contacts posed no problems and had a favourable effect on their learning (Table 3).

지식과 지식의 적용

Knowledge, application of knowledge and skills

• Gap이 있음. 지식이 부족함
  The majority of the clerks perceived gaps in their knowledge and half of them did not have the appropriate knowledge readily available (Table 4). 

• 전임상에서 배운것과 다른 지식을 요구함
  More than half the students agreed that clinical practice called for a different type of knowledge than they had acquired during pre-clinical training. 

• 전임상시기의 학습은 이해보다 인정받기 위함이었음
  Some students volunteered that assessment in the preclinical phase had stimulated them to study for recognition rather than understanding. 

• 행동과학영역의 지식은 충분, 행동과학>임상지식>기초지식
  Knowledge was perceived to be sufficient by half the students for the behavioural science domain and by 25.4% and 18.5% for the domains of clinical science and basic science, respectively. 

• 해부학, 약리학 부족
  Knowledge deficiencies were mostly perceived in anatomy and pharmacology (27 and 16 students, respectively).

• 스킬 준비는 잘 되어있음
  As for clinical skills, the majority of students felt themselves to be well prepared and able to perform clinical duties. 

• 증상을 recognize하기 어렵고, 병력청취와 신체진찰 어려움
  However, 43% had difficulty recognising symptoms and only a quarter felt confident about findings from history and physical examination. 

• 감독받고 있지 않음
  Almost a third of the students indicated that their findings were not checked by supervisors.

학습과 교육

Learning and education

• 독립적으로 공부할 수 있음
  Table 5 shows that the majority of the students felt capable of studying independently, found what they learned in clinical practice easy to retain, and studied because they were interested in a subject. 

• 평가가 학습을 guide 했음
  Assessment guided the learning of slightly over a third of the students. 

• 기존의 방식과 다르게 학습함
  One of the results of clerkship was that most students studied in a different way and 64.8% of students said they studied more intensively.

• 전임상 교육은 relevant하고 PBL은 좋은 준비과정임
  A large majority agreed that pre-clinical training had been relevant and that PBL had been a good preparation for clinical practice. 

• SP는 좋은 준비과정임
  Simulated patient (SP) contacts were thought to be good preparation by over half the students, although fewer students appreciated the discussion of the contacts afterwards. 

• BST는 좋은 학습경험. 
  Bedside teaching was seen as a good learning experience by many students, but fewer than half of them regarded the patient handover at the end of the day as such. 

• 주니어 의사는 70%가 좋음, 시니어 의사는 42.9%가 좋음
  Junior and senior doctors were regarded as good teachers by 70% and 42.9% of the students, respectively.

개방형

Open questions

학생들의 절반 이상이 실습생의 역할 및 책임에 대해 더 많은 정보를 원했습니다. 그들은 환자를 입원시키는 법을 배우기를 원했으며, 특히 신속하고 체계적인 신체 검사를 수행하는 방법을 배우고 싶었습니다.

More than half the students wanted more information about what was expected of them as clerks, their role and their responsibilities. They wanted to learn how to admit patients, particularly how to carry out a quick, structured, physical examination.

인식

The most salient early clerkship impressions fell into 7 categories (in order of frequency):

1 작업 부하 (증가); 1

2 환자 접촉 (높은 가치); 2

3 학습 (임상 연습에서 더 빠르고 더); 

4 동료와의 접촉 (직원 및 직원-학생 접촉에 관한 매우 긍정적이고 매우 부정적인 설명);

5 지식 (부족함); 5

6 새로운 환경 (병원 계층 구조),

7 의사의 직업 내용. 7

1 workload (increased); 1 

2 patient contact (highly valued); 2 

3 learning (more and faster in clinical practice); 3

4 contact with colleagues (very positive and very negative statements about staff and staff-student contact); 

5 knowledge (lack of); 5 

6 new environment (hospital hierarchy), and 6

7 the content of the profession of a medical doctor. 7

고찰

DISCUSSION

우리의 기대와는 달리 마스 트리 히트 PBL 학생들이 직면 한 문제는 전통적인 커리큘럼에서 학생들이보고 한 문제와 유사합니다.

Contrary to our expectations, the problems encountered by the Maastricht PBL students were similar to those reported by students in traditional curricula:

작업량

Workload

특정 활동에 소요 된 시간을 과대 평가하는 경향이보고 된 업무량을 부 풀릴 수 있었지만, 실습학생이 보고 한 시간이 전임상 모듈에서 학습 관련 활동에 대해 보고된 시간의 두 배 이상으로 학습량이 크게 증가했다.

Although the tendency to overestimate the amount of time spent on certain activities may have inflated the reported workload, the fact that the number of hours reported by the clerks was at least twice that reported for study-related activities in a pre-clinical module suggests a substantial increase in workload.15

지식, 지식 및 기술 적용

Knowledge, application of knowledge and skills

포커스 그룹 연구에서와 마찬가지로, 대부분의 학생들은 특히 기본 과학 지식에서 결함을 경험했습니다.

As in the focus group study, most students experienced deficiencies, especially in basic science knowledge.

학생들은 역사와 신체 검사를 수행 할 수 있다고 느꼈지만 결과를 해석하는 방법에 대해 불안했습니다. Regehr과 Norman은 또한 주어진 질병의 징후를 암기하는 능력은 환자가 임상 환경에서 증상을 호소했을 때 그 질병을 인지 할 수있는 능력을 보장하지 못한다는 것을 발견했다.

Students felt able to perform a history and physical examination, but were insecure about how to interpret the findings. Regehr and Norman also found that students’ ability to recite the appropriate signs of a given disease did not guarantee their ability to recognise that disease when a patient presented with symptoms in a clinical setting.18

학습 및 교육

Learning and education

그 결과 학생들은 임상실습 동안 내재적으로 동기 부여가 된 학습으로 전환했다. 학생들의 말에 따르면 평가 프로그램은 기계적 학습을 강화함으로써 역할을 수행 할 수 있습니다.

The results suggest that the students switched to more intrinsically motivated learning during clerkship. Remarks made by the students suggest that the assessment programme may play a role by reinforcing rote learning.

개선을위한 권장 사항

Recommendations for improvement

학생들은 전임상 (pre-clinical)과 임상 양측에서 조정을 제안했다. 여기에는 임상 전 단계에서 실제 환자와의 접촉 및 개인지도 그룹과 같은 구조화 된 교육 활동 및 임상 단계에서의 공부를위한 헌신적 인 시간이 포함되었습니다. 학생들은 사무직에 그들을 소개하는 더 좋은 방법을 개발할 수 있다고 제안했다.

Students suggested adjustments on either side of the  pre-clinical)clinical divide . These included contact with real patients in the pre-clinical phase and structured educational activities, such as tutorial groups, and dedicated time for studying in the clinical phase. Students also suggested that a better way of introducing them to the clerkships could be developed.

CONCLUSIONS

분명히, PBL은 마스 트리 히트 (Maastricht)에서 실행되는 방식에 기인 할 수 있지만,이 전환과 관련된 문제에 대한 만병 통치약은 아닙니다. 

Apparently, PBL is not a panacea for the problems associated with this transition, although this may be attributable to the way it is implemented in Maastricht.

학생들이 교실과 임상 환경 사이의 문화적 차이에 적응해야한다는 것은 필연적입니다. 그러나 우리는 교육자로서 책임을 회피하고 학생들의 발전을 저지하는 불만족스러운 상황을 받아들이지 않아야한다고 믿습니다. 본 연구는 이전의 질적 결과에 대한 정량적 인 확인을 제공함으로써 전환 문제의 심각성을 확인합니다

It is inevitable that students should have to adjust to  cultural differences  between the classroom and the clinical setting. However, we believe that as educators we should not shirk our responsibilities and accept an unsatisfactory situation that stifles students’ progress. The present study confirms the urgency of the transition problem by providing quantitative confirmation of our earlier qualitative findings.

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Med Educ. 2005 Jul;39(7):704-12.

Students' opinions about their preparation for clinical practice.

Prince KJ1, Boshuizen HP, van der Vleuten CP, Scherpbier AJ.

Author information

1

Skillslab, Faculty of Medicine, Maastricht University, 6200 MD Maastricht, The Netherlands. K.Prince@sk.unimaas.nl

Abstract

INTRODUCTION:

There are data that suggest that medical students do not feel sufficiently prepared for clinical practice in the clerkships. The transition from pre-clinical to clinical training causes problems.

OBJECTIVES:

To seek quantitative verification of qualitative findings from an earlier focus group study on problems medical students encounter when entering the clinical phase of undergraduate training.

METHODS:

At the start of the clinical phase, all Year 4 students at Maastricht Medical School were surveyed on the transition from pre-clinical to clinical training and its effects on workload, knowledge, skills and learning.

RESULTS:

The response rate was 67%. Students were uncertain as to how to behave and act, mainly because they did not know what was expected of them. They experienced a drastic increase in workload and a lack of time for studying. They considered themselves to be moderately prepared with regard to knowledge and they regarded their physical examination skills as satisfactory. Students reported having difficulty applying theoretical knowledge in clinical practice and perceived shortcomings in basic science knowledge. In addition, they felt compelled to change their learning strategies.

DISCUSSION:

The results of this study confirm the findings of the focus group study. The students experienced problems related to professional socialisation and workload and deficiencies in knowledge and the organisation of knowledge. A good starting point for improvement may involve exploring students' suggestions of an extensive introduction into the clerkships, a more gradual transition with regard to workload and closer integration of pre-clinical and clinical education.

Comment in

• The future is flexible? [Med Educ. 2005]

PMID:

 

15960791

 

DOI:

 

10.1111/j.1365-2929.2005.02207.x