의학교육에서의 돌봄, 역량, 전문가적 정체성(Adv Health Sci Educ Theory Pract. 2011)

의학교육에서의 돌봄, 역량, 전문가적 정체성(Adv Health Sci Educ Theory Pract. 2011)

Caring, competence and professional identities in medical education

Anna MacLeod

Background

의학 교육은 학습자가 전문적 정체성을 개발하고, 의학 기관을 구성하는 여러 담론에 참여하기 시작하는 과정입니다. 'Discourse'는이 논문의 중심 이론적 구성이며 상황, 이론가 등에 따라 다르게 이해되는 개념이다.이 경우 담론의 개념은 푸코의 획기적인 작업에서 구성된다 (1970, 1972, 1977 , 1978). 푸코 (Foucauld)의 관점에서 볼 때, 담론은 권력의 관계를 정당화하고 규칙과 관행의 집합에 의해 개최되는 지식이나 표현의 체계로서, 그것은 ''그들이 말하는 대상을 체계적으로 형성한다" 따라서, 담론은 이상적이거나 언어 적 범주가 아닙니다. 오히려 "담론에서 권력과 지식은 하나로 결합되어 있다"(Foucault 1978, 100면).

Medical education is the process by which learners develop professional identities and begin to engage with the multiple discourses that constitute the institution of medicine. ‘‘Discourse’’ is a central theoretical construct of this paper and is a concept that is understood differently, depending on contexts, theorists, etc. In this instance, the concept of discourse is constituted through Foucault’s landmark work (1970, 1972, 1977, 1978). From a Foucauldian perspective, discourse is a system of knowledge or representation that legitimates relations of power and that is held in place by sets of rules and practices ‘‘that systematically form the objects of which they speak’’ (1972, p. 49). Thus, discourse is not an ideal or a linguistic category; rather, ‘‘it is in discourse that power and knowledge are joined together’’ (Foucault 1978, p. 100).

푸코에 따르면, 담론은 세계에 의미를 부여하고 프로세스와 제도를 조직합니다. 보완, 도전 또는 경쟁, 구조 경험, 사회 및 기관의 담론 -이 경우 의학 교육을 통한 전문직 정체성 개발.

According to Foucault, discourses give meaning to the world and organize processes and institutions. Be they complementary, challenging, or competing, discourses structure experiences, society and institutions—and, in this case, the development of professional identities through medical education.

직업적 정체성의 개발과 특히 관련된 두 가지 담론 : 역량 그리고 돌봄

two discourses that are particularly relevant to the development of professional identities: competence and caring.

의사는 유능해야합니다. 그들은 또한 돌봄의 자질을 embody해야합니다. '능력'은 '가치에서 자유로운' 사실과 지식, 기술, 기술, '수행'또는 행동으로 기본 과학 언어와 관련됩니다. 이 학생들을 돌보는 것은 가치관, 관계, 태도, 동정심, 공감의 언어로 표현되며, 비 기술 적이거나 한 학생이 '의학의 개인적 측면'이라고 부릅니다 ... 능력은 자연 과학, 인문학을 돌보는 것. 능력은 지식과 기술의 질로 사람의 자질을 배려합니다. (좋고 좋은 1993, 91 쪽)

Physicians must be competent; they should also embody caring qualities. ‘Competence’ is associated with the language of the basic sciences, with ‘value free’ facts and knowledge, skills, techniques, and ‘doing’ or action. ‘Caring’ for these students is expressed in the language of values, or relationships, attitudes, compassion, and empathy, the nontechnical or as one student called it the ‘personal aspects of medicine.’…Competence is closely associated with the natural sciences, caring with the humanities. Competence is a quality of knowledge and skills, caring a quality of persons. (Good and Good 1993, p. 91)

Methods and methodology

Ethical considerations

Observation

I conducted 26 h of observations of a second-year PBL tutorial. The goal was to observe learners as they engaged in the process of developing professional identities in the context of a small group setting. The group observed was composed of 7 students: 5 women and 2 men; and, 1 tuorial leader, a man.

The data collected from observations of PBL tutorials included ‘‘headnotes’’ and ‘‘jottings.’’

Immediately following each tutorial, the headnotes and jottings were translated into fieldnotes—more detailed descriptions of the experiences and observations

Interviews

In-depth, open-ended, semi-structured interviews were conducted with medical students and medical educators.

Medical students

A ‘‘convenience sampling’’ technique (Creswell 2003) was used, meaning that I interviewed the first five students who responded. This technique has been critiques for lacking rigour; however, a Foucauldian position troubles oversimplified notions of sample size.

Medical educators

Medical educators were purposively selected because I was interested in speaking with people involved differently across the spectrum of medical education. I conducted nine semi-structured interviews with educators.

Traditionally, the interview has been considered a vehicle by which the knowledge of the interviewee was passed on to the interviewer (Grbich 2004). The two distinct parties barely interacted except by means of a structured interrogation. This research, however, was framed by the postmodern and considered the interview a conversation with multiple purposes, the format of which was constructed as the interview progressed.

Discourse analysis

The data were analysed using a Foucauldian discourse analysis approach. Foucauldian analyses of medicine, and medical education, are well-recognised as an effective method of critically analysing educational processes (See, for example, Armstrong 1995; Bleakley 2000; Hodges 2006; Hodges et al. 2008).

The analysis took into account the productiveness of discourses and paid particular attention to counter-discourses, noting that individuals are not passive recipients of discourse. As Carabine noted, ‘‘We should think of discourses as constantly being contested and challenged and therefore not necessarily always omnipotent’’ (2001, p. 273). Discourses also may serve to alter current, or to construct new power-knowledge, helping to re-determine what is and what is not (Carabine 2001) in the culture of medicine.

The hierarchy of discourses within the institution of medicine was also considered. For example, discourses of objective science and EBM are currently very authoritative in medical education, while discourses of the social components of care are marginalised. This ranking has established what constitutes normal, acceptable, and appropriate within the larger culture of medicine, hence, in medical education.

Pragmatically, the analysis was informed by Carabine’s (2001) 11-step description of a Foucauldian genealogical discourse analysis, which involves identifying themes; looking for inter-relationships; identifying discursive strategies and techniques; looking for absences and silences, resistances, and counter-discourses; and identifying the effects of discourse.

두 가지 중요한 담론: 역량과 돌봄

Two important discourses: competence and caring

역량 담론

Discourses of competence

역량 담론은 의학 교육에서 중요합니다 (Lingard 2009). 이 연구의 경우, 역량 담론은 의학의 기술적 측면(지식과 기술)을 언급한다. 의학적 역량(또는 옳은 답을 아는 것 / 사실을 갖는 것)은 기술 및 증거 기반 의학 (EBM)의 담론에 의해 구성되며, 경험적 증거와 회의론을 통해 역량이 성취된다는 전제에 기반하고있다. Group 1992; Sackett and Rosenberg 1995). 다양한 비평 (Goldenberg 2006)에도 불구하고, EBM은 학술 의학 교육에서 중요한 위치를 차지한다 (Lambert 2006, Mykhalovskiy and Weir 2004). 이것은 논란의 여지가 없는 근거에 따름으로써 의학의 복잡성을 줄일 수 있다는 약속에 기초하고있다 (Rhodes et al., 2006).

Discourses of competence are important in medical education (Lingard 2009). In the case of this study, discourses of competence refer to the technical aspects of medicine— knowledge and skills. Medical competence, or knowing the right answers/having the facts, is constituted by and through discourses of skill and evidence-based medicine (EBM), which is based on the premise that competence is achieved via empirical evidence and skepticism (Evidence Based Medicine Working Group 1992; Sackett and Rosenberg 1995). Despite various critiques (Goldenberg 2006), EBM occupies an important position in academic medical education (Lambert 2006; Mykhalovskiy and Weir 2004). This is based largely on its promise to reduce the complexities of medicine by deferring to indisputable evidence (Rhodes et al. 2006).

역량 담론의 핵심은 예를 들어, 의학 교육이 기술적이고 과학적인 발전에 초점을 맞추어야한다는 점을 공통적으로 고려하는 반면, 돌봄 담론과 관련된 교과 과정 활동은 benevolent한 add-on교과 과정으로 간주되는 경향이있는 것으로 나타났다. 즉, 돌봄 교과는 있으면 '좋은' 것이지만 의학의 '진정한 토대'는 아닌 것이다.

The centrality of a discourse of competence lead participants in this research, for example, to consider it commonsensical that medical education should focus on the development of technical and scientific, whereas curricular activities related to discourses of caring tended to be thought of as a benevolent curricular add-on that is, ‘‘nice’’ to do, but not the ‘‘true basis’’ of medicine.

돌봄 담론

Discourses of caring

이 담론은 의학의 사회적 측면에 관심을 갖는다 - 이 논문의 경우, 돌봄의 담론은 의학의 비 기술적 측면을 참조하십시오. 돌봄 담론과 관련된 관심사는, 역량 담론에 대한 초점 때문에, 종종 교육과정 시간과 관련하여 불리한 입장에 처해있다.

Discourses of caring focus on the social aspects of medicine—in the case of this paper, discourses of caring, then refer to the non-technical aspects of medicine. Concerns related to discourses of caring, because of the focus on discourses of competence, are often at a disadvantage with respect to curricular time.

역량, 돌봄, 전문직 정체성

Competence, caring and professional identities

전문직 정체성과 역량 담론

Professional identities and discourses of competence

역량 담론은 의학의 기술적 측면에 초점을 맞추고 객관적인 과학, 생물 의학 및 임상 기술을 포함합니다. Stephenson et al. (2001)은 "모든 의대생은, 많든 적든, 온갖 사실과 기술적 개입의 양과 복잡성에 압도 당했고, 죽음과 질병에 대해 불안해하며, 평가에 driven되고, 경쟁적이기를 권고받는다""(p. 867). 그들은 압력의 맥락을 설명하면서, 역량을 보여줄 필요성을 보여주었다.

Discourses of competence focus on the technical aspects of medicine and include objective science, biomedicine and clinical skills. Stephenson et al. (2001) noted ‘‘All medical students, to a greater or lesser degree, are overwhelmed by the quantity and complexity of the facts and technical interventions, anxious about death and disease, driven by assessment, and encouraged to be competitive’’ (p. 867). They described a context of pressure and the need to demonstrate competence.

The confident professional

The capable professional

The suitable professional

전문직 정체성과 돌봄 담론

Professional identities and discourses of caring

Weld Peabody는 "임상의의 중요한 특성 중 하나는 인류에 대한 관심이다. 환자의 보살핌의 비밀은 환자를 돌보는 데있다 "(882 쪽)라고 말했다. 돌봄 담론은 사회적 계급, 성별, 민족, 연령, 장소, 건강 및 발달, 물질적 및 문화적 요인, 심리 사회적 요인, 사회적지지, 생활 사건, 생활 과정  등과 같은 건강 및 복지에 영향을주는 사회적 결정 요인을 고려합니다. (Gabe et al. 2004). 그러므로 돌봄 담론은 관계, 태도, 감정과 같은 의학의 비 기술적 측면에 초점을 맞 춥니 다. 참가자들은 능력 담론 외에도 돌봄의 담론과 일치하는 바람직한 직업적 정체성을 보여주었습니다.

자비로운 전문가와 겸손한 전문가.

Weld Peabody (1927) noted ‘‘One of the essential qualities of the clinician is interest in humanity; for the secret of the care of the patient is in caring for the patient’’ (p. 882). Discourses of caring take into account social determinants that influence health and well being, including such issues as social class, gender, ethnicity, age, place, health and development, material and cultural factors, psycho-social factors, social support, life events, and the life course (Gabe et al. 2004). The discourses of caring, therefore, focus on the non-technical aspects of medicine, like relationships, attitudes, and emotions (Good and Good 1993). In addition to engaging in discourses of competence, participants also demonstrated desired professional identities consistent with discourses of caring: the benevolent professional and the humble professional.

The benevolent professional

The humble professional

돌봄 담론

자비로운 전문가

The benevolent professional

참가자가 사려 깊고 타인의 복지welfare를 고려한 방식으로 행동

Identified in the data when a participant acted in a manner that was thoughtful and that took into account the welfare of others

겸손한 전문가

The humble professional

고도로 특권을 부여받은 기관의 회원 (또는 회원이 됨)으로서의 지위에도 불구하고, 그녀 또는 그 사람이 unaffected and unpretentious(꾸밈없고 가식적이지 않음)을 증명하려고 시도했을 때

Identified in the data when a participant attempted to demonstrate that, despite their status as a member (or a becoming-member) of a highly privileged institution, she or he has remained unaffected and/ or unpretentious

역량 담론

자신감있는 전문가

The confident professional

참가자가 객관성, 과학 및 증거의 담론으로 강화 및 구성한 의심의 여지가없는 지위를 드러낼 때

Identified in the data when participants displayed a position of doubtlessness, reinforced by, and constituted through, discourses of objectivity, science, and evidence

유능한 전문가

The capable professional

시뮬레이션 된 학습 환경이든 실제 임상 환경이든 'equal to the task'것으로 기술하고 조치를 취한 경우 

Identified in the data when a participant described being ‘‘equal to the task’’ and taking action, whether this was in a simulated learning environment or an actual clinical setting

적합한 전문가

The suitable professional

의학 기관과 관련된 특권을 인정하고 기관의 규범을 강화함으로써 가치worthiness를 입증하려고 시도했을 때 

Identified in the data when a participant appeared to recognise the privilege associated with the institution of medicine and attempted to demonstrate worthiness by reinforcing the norms of the institution

담론 협상 과정에서의 전문직 정체성 발달

Developing professional identities while negotiating discourses

역량과 돌봄 모두가 의료의 실천에 기여합니다. 그러나, 학부 의학 교육에 대한 이 연구의 경우, 역량 담론과 관련된 전문적 정체성이 중심적인 관심사인 경향이 있었다.

Both competence and caring contribute to the practice of medicine; however, in the case of this study of undergraduate medical education, discourses of competence, and their associated professional identities, tend to be the central concern.

과학, 임상 기술, 사실적 지식의 회상에 대한 기관의 특권은 문헌에 잘 설명되어 있습니다. Ginsburg et al. (2005)는 "교육 과정에서 학생들은 종종 윤리적 기준과 행동의 침식으로 고통을 겪으며, 윤리적 문제에 대한 감수성을 잃어 버리고 자신이 '결코 되지 않으리라 맹세한 유형의 의사'가 될 것을 우려합니다. '(12 쪽). Hojat et al. (2004)

The institutional privileging of science, clinical skills, and factual recall are well described in the literature. Ginsburg et al. (2005) noted, ‘‘During the course of their education, students often suffer erosion of their ethical standards and behaviours, they lose sensitivity to ethical issues, and they fear that they are becoming the ‘kind of doctors’ they swore never to be’’ (p. 12). Hojat et al. (2004) elaborated:

의대 학년이 올라감에 따라 의대생의 75 % 정도가 학문적 삶과 의학계에 대해 더 냉소적 인 것으로보고되었습니다 .... '비인간 화'와 '외상적 탈-이상화'로 묘사 된 과정은 의대생의 냉소적 인 변신을 특징 짓는다. (935 페이지)

It has been reported that as many as 75% of medical students become more cynical about academic life and the medical profession as they progress through medical school…. Processes described as ‘dehumanization’ and ‘traumatic de-idealization’ characterize the cynical transformation of medical students. (p. 935)

역량에 중점을 두고 돌봄을 덜 강조하는 것은 학생들이 의학 교육을 탐색하고 협상하는 과정에서 공감능력이 뚜렷하고 꾸준하게 감소하는 데 기여할 수있다 (Beagan 1998; Ginsburg 외 2005, Hojat 외 2004).

The focus on competence and lesser emphasis on caring may contribute to a marked and steady decline in empathy as students navigate and negotiate medical education (Beagan 1998; Ginsburg et al. 2005; Hojat et al. 2004).

직업적 정체성 발달(자신감, 능력, 적합성, 겸손 또는 자비의 정체성)은 역량 및 돌봄에 관한 담론을 협상하는 과정에서 발생합니다 .그러나 이 연구 참가자들은 일방적으로 역량 및 돌봄에 관한 담론을 일방적으로 받아들이지 않았으며, 이진법적으로 상반되는 것으로 보지도 않았다. 오히려 참가자들은 역량과 돌봄이 각각 의학 교육에서 중요한 역할을한다는 것을 인식했습니다. 이것은 인터뷰 데이터(참가자들이 직업적 정체성에 관해 말한 것)와 관측 데이터(참가자가 어떻게 이 정체성을 "시도"했는지)를 비교할 때 가장 분명하게 드러났다.

The development of professional identities—be they identities of confidence, capability, suitability, humbleness or benevolence—occurs as discourses of competence and caring are being negotiated. Yet, these study participants did not unilaterally accept and/or engage discourses of competence and caring, or their affiliated professional identities, as binary opposites. Rather the participants recognised that competence and caring each play a role in medical education. This was most obvious when comparing the interview data—what participants said about professional identities—and the observation data—how participants ‘‘tried on’’ these identities.

요약

Summary

유능하고, 효과적이고 전문적인 의사 (Bowman and Hughes 2005, p.146)를 양성하려는 의학 교육은 여러 담론이 경쟁하는 맥락에서 발생합니다. 경쟁이 치열한 의학 교육의 문화에서, 유능하고 전문성을 갖추는 것은 종종 과학 및 증거의 개념과 관련이 있습니다 (Goldenberg 2006; Lambert 2006; Maudsley and Strivens 2000). '전문 역량'의 대안적인 구조가 제안되었지만 (Epstein and Hundert 2002 참조), 의학 교육은 흔히 과학적, 기술적/임상 기술에 집중하고 있습니다. 따라서 학습자는 자신감, 능력 및 적합성과 같은 역량 담론과 일치하는 전문적 정체성을 강하게 드러내었다.

Medical education, the process by which ‘‘competent, effective and professional doctors’’ (Bowman and Hughes 2005, p. 146) are developed, occurs in the context of competing discourses. In the highly competitive culture of medical education, becoming professionally competent is often connected to notions of scientism and evidence (Goldenberg 2006; Lambert 2006; Maudsley and Strivens 2000). While alternative constructions of ‘‘professional competence’’ have been proposed (see Epstein and Hundert 2002), medical education continues to focus frequently on the scientific and technical/clinical skills. Therefore, learners eagerly demonstrated professional identities consistent with discourses of competence: confident, capable and suitable.

Wear (2003)는 "성, 인종, 민족, 사회 계급, 육체적 또는 지적 능력, 성적 정체성, 또는 종교적 신념에 기초하여 사람들 간의 차이를 이해하고 존중할 필요성을 부인할 학술 의학 교육자는 거의 없다" (550 쪽)라고 말했다. 의학 교육에서 사회적 관심의 중요성에 대한 인식에도 불구하고, 돌봄 담론은 종종 부차적인 것이 된다. 그럼에도 불구하고 참가자들은 자비심 있고 겸손한, 돌봄 부함하는 전문직 정체성을 보여주었습니다. 점점 더 생의학적, 임상적 역량을 갖추는 과정에서 보살핌의 위치를 ​​유지하는 것은 학생들에게 불안의 근원입니다. Good and Good (1993)은 이에 대해 다음과 같이 논평했다.

Wear (2003) explained ‘‘Very few academic medical educators would deny the need for students to understand and respect differences among people based on gender, race, ethnicity, social class, physical or intellectual abilities, sexual identity, or religious beliefs’’ (p. 550). Despite recognition of the importance of social concerns in medical education, discourses of caring are often a secondary focus. Nonetheless, participants demonstrated professional identities consistent with caring: benevolent and humble. Maintaining a position of caring, while becoming increasingly biomedically and clinically competent, is a source of anxiety for students. Good and Good (1993) commented on this:

학생들의 초기 인터뷰는 돌봄을 중시하는 의사에 초점을 맞추고 있고, 자신이 과거에 경험했던 것과 다른 방식으로 의학을 실천하고자 하며, 그들이 알고있는 이상적인 의사의 모델에 부합하려는 것으로 특징 지어집니다. 그러나 능력이 필요한 기초 과학을 배우기 위해 압력이 커지면서 학생들은 점점 더 두 가지 목표의 균형을 맞출 수 없다는 두려움을 표현합니다. 즉, 'zero sum'일지도 모릅니다. 역량을 얻으려는 투쟁의 과정에서 학생들은 그들을 의학으로 이끌어준 돌봄의 자질을 잃을지도 모른다. (92 ~ 93 쪽)

Students’ earliest interviews are marked by a concern to become caring practitioners, to practice medicine differently than they have experienced it in the past, or to live up to the model of some ideal physician they have known. However, as the pressure grows to learn the basic sciences necessary for competence, students increasingly express fears that they will not be able to balance these two goals, that they may be a ‘‘zero sum,’’ that their struggle to achieve competence they may lose those caring qualities that led them to study medicine. (pp. 92–93)

사회 정의에 대한 마리아의 열정에도 불구하고, 의학 교육에 대한 요구와 역량 담론과 일치하는 직업적 정체성을 보여줄 필요성은 그녀가 다른 관심사를 제기하는 대신에 역량 담론과 일치하는 직업적 정체성을 증명하도록 압력을 받는 지점에 영향을 주었다. 의사가 된다는 것은 [역량 담론에 부합하는 전문직 정체성]과 [돌봄 담론에 부합하는 전문직 정체성] 사이의 균형을 맞추어야 할 필요를 협상하는 것을 의미한다.

Despite Maria’s passion for social justice, the demands of medical education and the need to demonstrate professional identities consistent with discourses of competence have influenced her to the point where she is pressured to demonstrate professional identities consistent with discourses of competence at the expense of raising other concerns. Becoming a physician, then, means negotiating the need to balance professional identities that are consistent with discourses of competence with those consistent with discourses of caring.

의학 교육 기관에 뿌리 내렸지만, 참여자는 의학 교육의 유일한 관심사로서 생의학 또는 임상 기술을 일방적으로 강화하지 못했습니다. 오히려 모든 교육자와 학생들은 역량담론과 돌봄담론을 서로 경쟁하면서 협상했습니다. 역량 담론에 대한 기관적 특권이 널리 드러나지만, 연구 참여자들은 또한 돌봄 담론과 일치하는 전문적 정체성을 입증했다. 이것은 연구 참여자가 임상의 복잡성을 인정하고 받아들인다는 것을 입증한다.

Although entrenched in the institution of medicine, no participant unilaterally reinforced biomedicine or clinical skills as the only concern of medical education. Rather, all educators and students negotiated the competing discourses of competence and caring. While the institutional privileging of discourses of competence is widely apparent, research participants also demonstrated professional identities consistent with discourses of caring. This demonstrates an acknowledgement, and an appreciation, on the part of the research participants of the complexities of the clinical encounter.

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Adv Health Sci Educ Theory Pract. 2011 Aug;16(3):375-94. doi: 10.1007/s10459-010-9269-9. Epub 2010 Dec 25.

Caring, competence and professional identities in medical education.

MacLeod A1.

Author information

1

Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada. anna.macleod@dal.ca

Abstract

This paper considers the multiple discourses that influence medical education with a focus on the discourses of competence and caring. Discourses of competence are largely constituted through, and related to, biomedical and clinical issues whereas discourses of caringgenerally focus on social concerns. These discourses are not necessarily equal partners in the enterprise of medical education. Discourses of competence tend to be privileged while those discourses of caring are often marginalised. Medical students learn to be physicians, and develop professional identities, in the context of these competing discourses. This paper documents a qualitative study designed to explore how professional identities are developed in the context of competing discourses. The study included a Foucauldian discourse analysis of medical education curriculum documents (67 problem-based learning cases in total), 26 h of observation of a small group learning experience (a problem-based learning tutorial), and in-depth, open-ended interviews with five medical students and nine medical educators at a Canadian medical school. The paper describes how professional identities are developed in relation to discourses of competence, noting that students displayed what they considered to be desirable professional identities of confidence, capability and suitability. Also explored are the professional identities demonstrated in relation to discourses of caring, including those of benevolence and humbleness. Despite current conceptualisations, medical education is ripe with potential. The data indicate Foucauldian "spaces of freedom"-sites at which the complexity of the practice of medicine and the interwoven natures of the discourses of competence and caring might be taken into account as a means of challenging taken for granted cultural norms and broadening the medical gaze.

PMID:

 

21188513

 

DOI:

 

10.1007/s10459-010-9269-9