성찰 능력이 의과대학기간의 문제행동과 연관되는가? (Acad Med, 2016)
Is Reflective Ability Associated With Professionalism Lapses During Medical School?
Leslie A. Hoffman, PhD, Ronald L. Shew, PhD, T. Robert Vu, MD, James J. Brokaw, PhD,
and Richard M. Frankel, PhD
성찰은 의학 및 기타 보건 전문직에서 전문성의 필수 요소로 널리 인용되었으며, 성찰은 학생들이 긍정적 인 역할 모델과 부정적인 역할 모델을 구분할 수 있도록 도와주는 도구로 제안되었습니다. 또한 학생들은 성찰을 통해 공식적, 비공식적, 잠재 커리큘럼에서 오는 상충하는 메시지들을 조화시켜야 합니다. 많은 사람들이 성찰을 구성하는 활동이나 과정을 기술했지만, 이 연구에서 우리는 성찰이란 의미를 명확히하거나 만들 목적으로 자신과 타인의 경험을 탐구하고 평가하는 것이라고 생각합니다. 성찰은 사고나 경험으로 "되돌아 가서turned back", 분석되고 해석되어 새롭거나 더 나은 이해를 얻을 수있는 과정"입니다. 성찰 과정에서 얻은 통찰력은 결과를 향상시키는 목적으로 향후 유사한 상황에 적용될 수 있습니다. 성찰을 자극하는 것은 종종 상황에 대한 기존의 지식과 가정에 의문을 갖게하는 "혼란스러운 딜레마"입니다. 의학의 이상적인 개념과 실천에서의 불일치는 의대생에게 그러한 자극을 제공하며,이 이분법을 성찰함으로써 그들의 경험을 탐색하고, 궁극적으로 잠재 커리큘럼의 요소를 수락하거나 거부 할 수 있습니다.
Reflection has been widely cited as an essential component of professionalism in medicine and other health care professions,1–5 and it has been proposed as a tool to help students learn to distinguish between positive and negative role models and to reconcile the conflicting messages from the formal, informal, and hidden curricula.6 Although many have described the activities or processes that constitute reflection, in this study, we consider it to be an exploration and appraisal of one’s own and others’ experiences for the purpose of clarifying or creating meaning.7 Reflection is a process by which one’s thoughts are “turned back” to an event or experience so it can be analyzed and interpreted to gain a new or better understanding. The insights gained during the reflective process then can be applied to similar situations in the future with the goal of improving outcomes.8 The stimulus for reflection is often some “disorienting dilemma” that causes one to question one’s knowledge and assumptions about a situation.9 The discrepancy between one’s idealized notion of medicine and the reality of medical practice provides such a stimulus for medical students, and reflecting on this dichotomy often can help them navigate among their experiences and ultimately accept or reject elements of the hidden curriculum.10,11
프로페셔널리즘을 증진하고 평가하는 도구로서의 성찰적 글쓰기가 의과 대학 사이에서 인기를 얻고 있습니다. 2008 년 설문 조사에 따르면 내과 (IM) 임상실습의 35 %가 학생들이 임상실습에서 성찰문 작성을 요구한다는 사실을 알게되었으며, 이를 통해 학생들이 의사 소통 기술과 전문성을 개발하는 데 도움이된다는 믿음을 나타 냈습니다.
Reflective writing as a tool to promote and assess professionalism is growing in popularity among medical schools. A 2008 survey found that 35% of internal medicine (IM) clerkship directors required students to engage in reflective writing during their clerkship, indicating a belief that the practice helped students to develop communication skills and professionalism.
많은 의대가 학생들의 전문성 개발을 촉진시키기 위해 성찰 작문 교과 과정을 도입했지만, 이러한 실천을 뒷받침하는 증거는 대체로 일화 적이다. 학문 반성이 학생들의 전문성을 향상 시키거나 더 중요하게 반성의 결여가 전문성 부족의 위험을 증가 시킨다는 경험적 증거는 없다.
Although many medical schools have introduced reflective writing curricula to foster students’ professional development, the evidence to support this practice is largely anecdotal; no studies have provided empirical evidence that reflection enhances students’ professionalism or, more important, that a lack of reflection increases the risk of professionalism lapses.
Method
Evaluation of professionalism at IUSM
the Student Promotions Committee (SPC) was charged with evaluating competency deficiencies among students and referring them to qualified individuals for remediation. Between 1999 and 2009, 191 students were referred to the SPC for 317 separate competency deficiencies. Deficiencies in professionalism, selfawareness, and moral reasoning were the most frequently cited, accounting for over 55% of all citations (29.3%, 17.7%, and 9.1%, respectively).14
The SPC compiles and evaluates descriptive comments from course/clerkship directors, clinical preceptors, and other faculty/staff, such that citations for deficiencies are issued by consensus. Prior studies have shown that similar descriptive/qualitative methods of evaluation can achieve a level of validity and reliability that is sufficient for high-stakes decisions.16,17 Examples of behaviors that would be deemed unprofessional or lacking in self-awareness or moral reasoning include
chronic tardiness or unexcused absences from clinic or other required activities,
incomplete assignments,
plagiarizing notes in the electronic medical record, or
using disrespectful language toward or about a patient.
Study population and sample
Our study population consisted of all medical students who matriculated at IUSM between 2001 and 2009 (N = 2,700).
Assessment of reflective ability
The primary source for determining students’ reflective ability was the professionalism journal entries they submitted during their eight-week IM clerkship.
We measured students’ reflective ability using a validated scoring rubric19 that included seven levels of reflection (see Table 1).
Table 1
Levels of Reflection Measured by the Reflective Ability Rubric Used in a Study of Medical Students’ Reflective Ability and Professionalism Lapses, Indiana University School of Medicine, 2001 to 2009
0 과제에 응답하지 않음
0 Does not respond to the assignment
1 배운 교훈을 언급하지 않고 절차 / 사례 / 설정을 설명합니다.
1 Describes procedure/case/setting without mention of lessons learned
2 사례없이 배운 교훈에 대한 의견만 기술
2 States opinions about lessons learned without supporting examples
3 자기 자신만을 언급하면서 배운 교훈을 피상적으로 정당화한다.
3 Provides superficial justification of lessons learned citing only one’s own
4 도전, 기술 및 교훈에 관한 예를 잘 뒷받침하는 합리적인 토론을 제공하고 다른 사람이나 다른 출처로부터 피드백을 얻는 것을 포함합니다
4 Offers reasoned discussion well supported by examples regarding challenges, techniques, and lessons learned, includes obtaining feedback from others or other sources
5 과거의 경험이 현재의 행동에 미치는 영향을 분석합니다.
5 Analyzes the influence of past experience on current behavior
6 위의 모든 것을 통합하여 학습에 관한 결론을 이끌어 내고 미래의 학습 또는 행동을위한 전략을 제공하며 전략의 효과를 결정하는 증거를 제시합니다
6 Integrates all of the above to draw conclusions about learning, provides strategies for future learning or behavior, and indicates evidence for determining the effectiveness of those strategies
Rater training and reflection scoring
Two authors (L.A.H., R.L.S.) were trained by one of the rubric’s authors according to its published guidelines.19 Those two authors scored 5 journal entries together, followed by 10 entries independently, at which point we calculated interrater reliability (IRR) using Cohen weighted kappa.27 A weighted kappa measurement was selected for this study to allow for scaled degrees of agreement, such that a small discrepancy in scoring received greater weight than a large discrepancy.
Once we achieved an IRR of at least 0.8, one of the raters (L.A.H.) scored 559 journal entries written by the 300 students in the sample.
Statistical analysis
We included gender because a previous analysis at IUSM found that males were significantly more likely to have been cited for competency related deficiencies.14 We included age at matriculation because a recent study found that students aged 31 or older were significantly more likely to have academic difficulties in medical school,28 and we were interested in whether this group of students had been cited for professionalism deficiencies as well.
We used logistic regression analysis to examine the relationship between reflective ability and professionalism lapses. The dependent variable was whether or not a student had been cited for a professionalism deficiency during medical school. The independent variables were the student’s (1) gender, (2) age at matriculation, and (3) reflection score. All independent variables were entered into the model in one step.
결과
Results
Ninety-two students from the study population had been cited for competency deficiencies related to professionalism; The control group included 230 randomly selected students who had no SPC history but at least one journal entry for us to score. Characteristics of the two groups are summarized in Table
Results of the t tests are presented in Table 3.
성찰점수가 높을수록 SPC 가능성 낮음.
The odds ratio for reflection score was 0.64 (95% confidence interval [CI]: 0.47–0.87; P < .01; see Table 4), This increase in likelihood of having been cited for a professionalism lapse can be expressed by the inverse of the odds ratio (1/0.64 = 1.56; 95% CI: 1.15–2.13). Thus, for every 1-point decrease in reflection score, a student was 1.5 times more likely to have been cited for a professionalism lapse during medical school. Neither gender nor age at matriculation was associated with likelihood of having been cited for a professionalism lapse.
고찰
Discussion
현재의 문헌은 성찰 능력이 프로페셔널리즘의 필수 요소임을지지한다. 의사들 사이에서 성찰의 결여가 일부 프로페셔널리즘 실책의 잠재적 원인으로 지적되었습니다. 우리의 연구는 이러한 주장을 뒷받침 할 수있는 경험적 증거를 제공합니다. 성찰 점수가 낮으면 의대에서 프로페셔널리즘이 상실된 것으로 밝혀 졌을 확률이 높습니다.
Current literature supports that reflective ability is an essential component of professionalism.2–4,8 A lack of reflection among practitioners has been cited as a potential cause for some lapses in professionalism.29 Our study provides empirical evidence to support these claims by showing that lower reflection scores are associated with an increased likelihood of having been cited for a professionalism lapse during medical school.
이 연구의 결과가 성찰과 프로페셔널리즘 사이의 연관성을 지적했지만,이 관계의 정확한 성격은 여전히 불분명하다. 내과 실습 관리자에 대한 설문 조사에 따르면 성찰은 학생들의 프로페셔널리즘을 향상 시켰다고 믿었으며, 따라서 임상실습 동안 성찰하는 글쓰기를 학습 활동으로 사용했습니다. 이 개념은 내러티브 의학narrative medicine의 기초이기도합니다. 의사는 환자의 공감, 전문성 및 신뢰성을 높이기 위해 환자의 이야기를 이해하려고 노력합니다. 내러티브 의학 선택 과목에 참여한 후, 학생들은 성찰에 참여하는 것이 공감력을 키우고 환자 중심의 치료를 제공함으로써 개인적으로나 직업적으로 개발에 도움이되었다고 인식했습니다.
Although the findings of this study point to an association between reflection and professionalism, the exact nature of this relationship is still unclear. A survey of IM clerkship directors revealed that most believed that reflection enhances students’ professionalism, and thus they used reflective writing as a learning activity during their clerkship.12 This notion is also the foundation of narrative medicine, in which physicians seek to understand patients’ stories of illness to enhance their empathy, professionalism, and trustworthiness.30 After participating in a narrative medicine elective, students perceived that engaging in reflection had helped their development both personally and professionally by increasing their capacity for empathy and for providing patient-centered care.31
어떤 사람은 성찰이 personal and professional growth와 학습의 증거를 제공함으로써, 학생들이 자신의 능력을 입증 할 수있는 수단이라고 보기도 한다. 성찰적 글쓰기에 대한 기존 연구는 주로 학생들의 전문적 태도와 가치에 대한 통찰력을 얻기 위해 질적 인 방법에 의존해 왔습니다. 그러나, 이러한 방법은 본질적으로 시간이 많이 걸리고 주관적 일 수 있습니다. 양적 접근은 프로페셔널리즘을 평가하는보다 효과적이고 신뢰성있는 방법을 제공 할 수있다. 그러나, (양적 접근을 활용하기 위해서는) 성찰 능력이 프로페셔널리즘에 대한 유효한 프록시 척도라는 실질적인 증거를 먼저 요구할 것이다.
Others view reflection as a means for students to demonstrate their competence by providing evidence of their personal and professional growth and learning.34 Prior studies of reflective writing largely have relied on qualitative methods to gain insights into students’ professional attitudes and values35,36; however, these methods can be time consuming and subjective in nature. A quantitative approach could provide a more efficient and reliable method to assess professionalism; however, it first would require substantial evidence that reflective ability is a valid proxy measure for professionalism.
Limitations
Conclusions
학생들이 성찰의 중요성을 인식하게하려면, 성찰을 중시하고 성찰하는 실천가를 개발하는 것을 목표로하는 문화가 동반되어야 합니다 .8
For students to recognize the importance of reflection, activities must be accompanied by a culture that values reflection and aims to develop reflective practitioners.8
23 Aronson L, Niehaus B, Hill-Sakurai L, Lai C, O’Sullivan PS. A comparison of two methods of teaching reflective ability in year 3 medical students. Med Educ. 2012;46:807–814.
Is Reflective Ability Associated With Professionalism Lapses During Medical School?
Author information
- 1
- L.A. Hoffman is assistant professor, Department of Anatomy and Cell Biology, Indiana University School of Medicine, Fort Wayne, Indiana. R.L. Shew is senior lecturer, Department of Anatomy and Cell Biology, Indiana University School of Medicine, Indianapolis, Indiana. T.R. Vu is associate professor of clinical medicine and associate director of the medicine clerkship, Department of Medicine, Indiana University Schoolof Medicine, Indianapolis, Indiana. J.J. Brokaw is associate professor, vice chair for education, and director, Indiana University Center for Anatomical Sciences Education, Department of Anatomy and Cell Biology, Indiana University School of Medicine, Indianapolis, Indiana. R.M. Frankel is professor of medicine, Department of Medicine, and director, Walther Program in Palliative Care Research and Education, Simon Cancer Center, Indiana University School of Medicine, Indianapolis, Indiana.
Abstract
PURPOSE:
METHOD:
RESULTS:
CONCLUSIONS:
- PMID:
- 26760059
- DOI:
- 10.1097/ACM.0000000000001094
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