임상실습 준비시키기: 레지던트 셰도잉 프로그램(Acad Med, 2012)

임상실습 준비시키기: 레지던트 셰도잉 프로그램(Acad Med, 2012)

Preparing Students for Clerkship: A Resident Shadowing Program

Simon R. Turner, MD, MEd, Jonathan White, MD, PhD, Cheryl Poth, PhD, and

W. Todd Rogers, PhD

전임상에서 임상 교육으로의 전환은 많은 의대생에게 어렵습니다 .1 그들이 직면하는 도전 가운에는 낯선 환경, 새로운 역할, 임상 지식 및 기술 부족이 있습니다. 임상실습을 시작하는 학생들은 자신에게 기대되는바를 잘 모르기 때문에 어떻게 행동하고 행동해야하는지에 대해 불확실해한다. 학생들은 50 %의 학생들이 임상실습에 대한 준비가 잘되어 있지 않다고 느꼈으며, 93 %는 학생들의 좋은 introduction이가 전환을 더 쉽게 만들 것이라고 생각했습니다. 교육자들도 마찬가지로 학생들이 임상실습을 시작하기에 준비가 덜 되었다고 생각한다.

The transition from preclinical to clinical education is difficult for many medical students.1 Among the challenges they face are unfamiliar environments, new roles, and a lack of clinical knowledge and skills. Students entering clerkship may be uncertain as to how to behave and act, mainly because they (dont) know what (is) expected of them.2 Radcliffe and Lester1 found that 50% of students did not feel well prepared for clerkship, and 93% thought a good introduction would make the transition easier. Educators, too, find students unprepared to begin clinical duties;

학생들을 임상실습에 준비시키는 강의 프로그램은 종종 임상 trainee와 직접 관련이없는 지식과 기술에 중점을 둡니다.

Classroom programs intended to prepare students for clerkship often focus on knowledge and skills that are not directly relevant to clinical trainees.4

의대생을 임상 환경에 초기에 노출시키는 프로그램은 유망한 결과를 보여 주었고, 이는 situated learning이론과 legitimate peripheral participation 이론을 통해 이해할 수 있습니다 .6 새로운 임상 지식과 기술을 실시간으로 관찰하거나 적용 할 기회. 또한 초기 임상 경험은 학생들의 임상실습에 대한 불안감을 줄이고, 역할에 대한 명확성을 높이는 것으로 나타났습니다 .7

Programs that expose medical students to the clinical environment early on have shown promising results, which may be understood through the theories of situated learning5 and legitimate peripheral participation.6 The chance to observe, or even apply, new clinical knowledge and skills in a real-world setting reinforces students learning.5 Furthermore, early clinical experiences have been shown to decrease students anxiety about clerkships and increase their clarity regarding their roles.7

그러나 조기 임상 경험의 기회는 범위와 접근 방식 모두에서 종종 제한적입니다. 최근의 experience-based preparatory courses에 따르면, 그들은 측정 가능한 목표가 부족한 경향이 있으며 대다수 (83 %)는 하루부터 1 주일 정도에 불과하다.

Yet, opportunities for early clinical experiences are often limited in both scope and approach. According to a recent review of experience-based preparatory courses, they tend to lack measurable objectives and the vast majority (83%) last only between one day and one week.8

임상 준비 프로그램의 효과를 향상시키는 한 가지 방법은 가까운 동료를 교사이자 멘토로 이용하는 것입니다. 그러한 프로그램은 학습자와 교사 간의 사회적 및 인지적 일치를 높여주는 등 잘 확립 된 편익을 가지고있다. 

• 니어 피어 학습의 한 가지 형태는 저학년 학생이 상급 학생이나 레지던트임상 환경에서 관찰하고 관찰하고 때로는 임상 활동에 참여를 셰도잉하는 것이다.

• 영국의 의대생이 HO를 shadowing할 때, 그들은 자신의 필요에 직접적으로 관련된 경험을 얻었고, 직장 환경에 익숙해졌으며, 미래의 역할을 지향하고 구체적이고 관련 의학 지식을 배웠다고보고했습니다.

• 마찬가지로, 1 학년 학생들이 3 학년 학생들을 shadow한 프로그램에서 그들은 의학 실습, 의사가되는 과정, 의료 제공자, 실제 환자의 본질 및 의학 절차에 대해 알게되었습니다 .11

One way to enhance the effectiveness of preparatory programs is to use near-peers as tutors and mentors. Such programs have well-established benefits, including improved social and cognitive congruence between learner and teacher.9 

• One form of near-peer learning is shadowing, in which junior students follow senior students or residents in a clinical setting, observing and sometimes participating in clinical activities. 

• When graduating British medical students shadowed house officers, they reported that they gained experience directly relevant to their needs, became familiar with their work environment, were oriented to their future role, and learned specific and relevant medical knowledge.10 

• Similarly, in a program where first-year students shadowed third-year students, they learned about the practice of medicine, the process of becoming a doctor, providers of healthcare, the nature of real patients and the procedures of medicine.11

프로그램

The Program

개발

Development

Drawing on our own experiences as students and teachers of medicine, in 2009, we developed a program to prepare students for clerkship and to address some of the issues faced by other preparatory programs. Our program applied the benefits of near-peer, experience-based shadowing programs to preclinical students, capitalizing on the knowledge, skills and experience of residents. 

기대효과

We hoped that, by exposing students to and having them participate in clinical activities, they would both better understand the clinical environment and the trainee’s role within it, and gain the knowledge and skills needed to perform that role. From a practical point of view, we also wished to develop a program with minimal financial cost and administrative effort.

대상과 이유

The program allows a first-year medical student to shadow a volunteer first-year resident from any specialty on multiple occasions over an extended period. 

• We chose first-year students because of the potential for the greatest impact on their education as well as the potential to optimize the amount of time for students to form a long-term relationship with their resident throughout their training. 

• We chose first-year residents because of their wide variety of clinical rotations, their high level of clinical expertise relative to medical students, and their closeness to students in age and training. 

1년차 레지던트지만 충분

We hoped this proximity would foster near-peer interaction, a better understanding of student’s needs, and closer relationships between students and residents. Although the clinical abilities of first-year residents are not as developed as those of more senior residents, we felt that their knowledge and skills, relative to those of first-year students, were sufficient to allow effective teaching.

묘사

Description

모집

At the beginning of the academic year, we present the program to students and residents at their respective orientations and invite them to participate. Recruitment continues with a series of e-mail invitations and follow-up question-and-answer sessions. 

Shadowing 기간, 시간

Once all participants have been determined, each first-year medical student is randomly assigned to shadow one first-year resident during clinical activities for four to six hours, once per month, for eight months (32–48 hours direct contact per year). Sessions are scheduled during the residents regular work duties and when the student is free of other academic obligations. Students can, at their discretion, shadow at night or on the weekends; however, because our institution already allocates students one morning and one afternoon per week to study or pursue additional learning opportunities (such as shadowing), concerns over work-hour restrictions are mitigated. We encourage participants to select shadowing times and settings that are mutually convenient and that provide a variety of clinical experiences. 

Shadowing 범위

We place no limitations on the setting of the shadowing experiences, as long as they are clinically based. Possible situations include morning rounds, outpatient clinics, the emergency room, the operating room, labor and delivery wards, and evenings when the resident is on call. 

레지던트 관리감독

A student’s observation of and participation in clinical activities must always be under the resident’s direct supervision, and the resident must inform their own supervising physician or team of the student’s presence at least a day in advance.

관련 자료 제공

We have developed and distributed to the program’s various stakeholders a number of documents with differing purposes. 

• 학습과 관련된 문서
  To optimize their learning, the students (and participating residents) receive documents containing objectives related to clinical medicine, a description of the life and work of a clinical trainee, and the CanMEDS competency framework.12 

• 안전한 교육환경을 위한 문서
  To ensure a safe and educational atmosphere for students and patients, and to improve the fidelity of the intervention, they also receive a document (available to readers upon request from the author) that describes the program format, including recommended shadowing frequency, duration and settings, policies related to harassment and abuse, and rules regarding student roles and resident supervision. 

학생이 잡일을 해서는 안됨 

• Included in these rules is the stipulation that students are not to be used solely for educationally worthless “scut work,” but should be exposed to all parts of the resident’s job so they can better understand the day-to-day work. 

레지던트는 관리감독을 잘 해야함

• Residents must carefully judge and monitor the amount of patient care responsibility they give to students, always keeping in mind the student’s very junior level and the fact that they are often interacting with patients for the very first time. 

• In all settings, and especially with regards to procedural skills, writing orders, or providing medical advice, students must be closely supervised and never placed in a situation that compromises patient safety.

• The ultimate authority regarding a student’s activities rests with the patient’s attending physician. 

최대한의 학습을 위한 권장사항

• The documents also include suggestions to maximize the learning potential of the shadowing sessions. For example, we encourage participants to schedule sessions for times when the clinical setting is busy enough to be interesting and educational, but not so hectic as to make teaching and interaction difficult.

행정비용 최소화를 위한 노력

• Aside from the initial development of the learning objectives and program description, the administrative effort required to run the program consists solely of the short recruitment process and answering occasional e-mails from participants. 

• During the program, students and residents also receive monthly e-mail reminders to schedule shadowing sessions. These e-mails include responses to frequently asked questions and suggestions to deal with any problems encountered, and serve as a distribution mechanism of program documents. 

• In the program’s inaugural year, the administrative duties were performed by one of the authors, at that time a graduate student. In the following years, these duties have been taken over by an administrative staff member within the Faculty of Medicine.

도입

Implementation

신청자 중 무작위로 83명(레지던트 신청자와 동수) 배정

We therefore randomly selected 83 students to be partnered with residents. The remaining 90 students formed a control group for comparison.

Shadowing한 시간

Students in the intervention group reported a mean total shadowing time of 44.5 hours during their first year of medical school, significantly greater than any informal shadowing carried out independently by students in the control group (28.6 hours, P < 0.001). The mean reported length of a shadowing session was 4.13 hours (SD = 1.28 hours, range 1–8 hours). 

Shadowing한 장소

Students reported participating in a wide variety of clinical settings, including 

• inpatient ward rounds, 

• outpatient clinics, 

• the emergency room, 

• labor and delivery, 

• scrubbing in the OR, and 

• on call at night. 

Shadowing한 활동

The activities in which they spent the most time were (in descending order) 

• history taking, 

• charting, 

• physical examination, and 

• CanMEDS behaviors.

평가

Assessment

Of the 63 students in the program who responded to the questionnaire, 

• 즐거움 59 (93.6%) stated they enjoyed participating, 

• 동료에게 권장 58 (92.1%) would recommend the program to a colleague, and 

• 재참여 의사 57 (90.5%) would participate again. 

또 해야하는가?

When asked if the program should be available again the following year, 

• all but one (98.4%) of the responding intervention group students, 

• all 57 (100%) of the responding control group students, and 

• 66 of the 70 (94.3%) responding residents agreed.

학생의  향상도

• The intervention group had a significantly larger increase in their mean score on the preparedness scale (SD = 0.85) from pre to post intervention than did the control group (SD = 0.11, P = 0.005). 

• Fifty (79.3%) of the responding intervention group students and 52 (74.3%) of the responding residents thought that participation in the program had better prepared the students for third-year clinical rotations. 

• The majority of students and residents thought that participation in the program improved the student’s medical knowledge, the quality of their interactions with other health professionals and with patients, and their ability to perform physical examinations and take medical histories.

Lessons Learned

우리의 더 큰 평가의 한 부분으로 인터뷰 한 레지던트들은 

• 예상보다 적은 시간과 노력을 들여야했고, 

• 더 적은 수의 일이 필요하다는 것을 알았다면 더 많은 주민들이 가입했을 것이라고 말했다. 

• 또한 기본 임상 지식의 보충, 

• 전문성에 대한 깊은 이해, 그리고 

• 부담이 적은 환경에서 교육을 실습해볼 수 있는 기회

....등 참여로 인한 혜택을보고했습니다. 레지던트를 모집 할 때 이러한 혜택을 강조해야합니다.

The residents interviewed as part of our larger evaluation stated that participation required even less time and effort than they had expected, and that more residents would have signed up had they known how little work was required. They also reported benefits for themselves from participating, including the cementing of basic clinical knowledge, a deeper understanding of professionalism, and the opportunity to practice teaching in a low pressure setting. These benefits should be emphasized when recruiting residents to participate.

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Acad Med. 2012 Sep;87(9):1288-91.

Preparing students for clerkship: a resident shadowing program.

Turner SR1, White J, Poth C, Rogers WT.

Author information

1

University of Alberta, Edmonton, Alberta, Canada. sturner@ualberta.ca

Abstract

The preparation of medical students for clerkship has been criticized, in terms of both students understanding of their new role as clinical trainees and their ability to carry out that role. To begin to address this gap, the authors report the development, implementation, and assessment of a novel program in which first-year medical students shadow first-year residents during their clinical duties. The program matches each student to a single resident, whom they shadow for several hours, once per month, for eight months. In the programs inaugural year (2009-10), 83 student-resident pairs participated; over 70% responded to pre- and post-intervention questionnaires, which included an 18-item preparedness scale. The authors used those responses to evaluate the program. Compared to students in a control group, the students in the program assessed themselves as better prepared to learn in a clinical setting. The low-cost student-resident shadowing program described in this article provided an early and structured introduction to the clinical environment, which may help prepare students for the transition into clerkship.

PMID:

 

22836844

 

DOI:

 

10.1097/ACM.0b013e3182623143