프로페셔널리즘 평가를 위한 블루프린트: 체계적 문헌고찰(Acad Med, 2009)
A Blueprint to Assess Professionalism: Results of a Systematic Review
Tim J. Wilkinson, MB, ChB, M Clin Ed, PhD, FRACP, Winnie B. Wade, MA (Curriculum Studies), MA (Education), and L. Doug Knock, MSc
그러나 프로페셔널리즘을 개념으로 정하는 것은 어려울 수 있습니다 .1 그것이 중요하다는 것은 보편적으로 받아들여지며, 대부분의 사람들은 그것이 없을 때를 알아채지만, 정의는 광범위하다 .2,3
Yet, professionalism as a concept can be difficult to pin down.1 There is universal acceptance that it is important, and most people agree when they see that it is missing, yet definitions range broadly.2,3
프로페셔널리즘이 위협받고 있다는 사실은 그것을 더 잘 측정 할 필요성을 강조한다. 예를 들어, 외부 규제는 개선을위한 내재적 동기 부여를 약화시킬 수 있습니다. 또한 근무 시간이 짧아진다는 것은 일부 의사들에게 지속적으로 헌신과 책임감 개발도 어려워 질 수 있음을 의미합니다. 마지막으로 재정적 인센티브와 불이익은 개인적, 도덕적, 윤리적 책임과 경쟁 할 수 있습니다.
The need to measure professionalism better is further highlighted because it is under threat. For example, external regulation may undermine intrinsic motivation to improve. Also, shorter working hours mean that some doctors may find it harder to develop an enduring commitment and sense of accountability. Finally, financial incentives and disincentives can compete with personal, moral, and ethical responsibilities.
예를 들어 의사의 왕립 대학 (Royal Colleges of Physician), 의료 전문직업성 프로젝트 (Medical Professionalism Project)에서 야기 된 의료 전문성에 관한 헌장, 훌륭한 의료 실무에 관한 영국의 일반 의학 협의회 (General Medical Council) 등은 프로페셔널리즘에 관한 합의 성명을 개발하는 중요한 작업을 하였다
there has been important work in developing consensus statements on professionalism—for example, from the Royal Colleges of Physicians,11,13 the Charter on Medical Professionalism arising from the Medical Professionalism Project,14 and the British General Medical Council statements on good medical practice.15
프로페셔널리즘을 측정하거나 평가하는 것은 두 가지 주요한 문제로 방해 받는다.
프로페셔널리즘에 대한 많은 정의가 있지만, 이들은 종종 너무 광범위하여 쉽게 평가하기 어렵다. 또한 합의가 없으며, 프로페셔널리즘에 대한 견해가 시간이 지남에 따라 바뀔 수도 있습니다 .3
두 번째 문제는 프로페셔널리즘을 측정 할 도구를 개발하려는 많은 시도와 진전이 있었습니다. 그러나 우리는 하나의 도구가 복잡한 영역을 적절하게 평가할 수있는 경우는 거의 없다는 것을 알고 있습니다.
Measuring or assessing professionalism is hampered by two major problems.
Although there are many definitions of professionalism, these are often so broad that they do not lend themselves to aspects that are easily assessable. Furthermore, there is no agreed consensus, and views on professionalism may change over time.3
The second problem is that there have been a number of attempts to develop tools to measure professionalism, and much progress has been made. Yet, we know from other lessons learned in assessment that single tools are rarely able to assess complex areas adequately.
개인의 프로페셔널리즘에 대한 여러 스냅샷을 취한 다음,
전체를 조합하여 그 사람의 강점과 약점에 대한 명확한 그림을 개발하고,
총괄적 의사 결정의 기반이 될 근거 자료를 제공 할 수있는
... programmatic approach가 필요할 것입니다 16,17 .18
A programmatic approach is likely to be needed16,17 whereby
multiple snapshots of an individual’s professionalism can be taken and
then collated into a whole to develop a clear picture of that person’s strengths and weaknesses and to
provide a body of evidence on which to base summative decisions.18
방법
Method
다섯 단계
We carried out this study during 2007– 2008 in five stages:
(1) a literature review of definitions of professionalism,
(2) a thematic analysis of the definitions of professionalism,
(3) a literature review of tools to assess elements of professionalism,
(4) creation of a blueprint whereby the elements of professionalism are matched to relevant assessment tools, and
(5) identification of assessment gaps.
Each of us undertook a thematic analysis of the definitions of professionalism by identifying the key elements from each definition.
We then discussed any areas of difference and agreed on consensus elements and themes.
We clustered those elements by taking account of two aims:
to cluster them into similar attributes and
to cluster them into themes that might use similar assessment techniques.
From this, we aimed to develop a working definition of professionalism that captured all the relevant aspects. Alongside this was the need to clarify the behavioral manifestations of some key elements if the definitions were unclear.
결과
Results
프로페셔널리즘 정의
Defining professionalism
A classification of the themes arising from definitions or interpretations of professionalism, mapped against the relevant references, is offered in Table 1.
Table 1. The Authors’ Classification of Themes and Subthemes, Arising From Definitions or Interpretations of Professionalism Found in the References Indicated*
Adherence to ethical practice principles, including but not restricted to:
● Honesty/integrity
● Confidentiality
● Moral reasoning None
● Respect privileges and codes of conduct
Effective interactions with patients and with people who are important to those patients, including but not restricted to:
● Respect for diversity / uniqueness
● Politeness / courtesy / patience
● Empathy / caring / compassion / rapport
● Manner / demeanor
● Include patients in decision making
● Maintain professional boundaries
● Balance availability to others with care for oneself
Effective interactions with other people working within the health system, including but not restricted to:
● Teamwork
● Respect for diversity / uniqueness
● Politeness / courtesy / patience
● Manner / demeanor
● Maintain professional boundaries
● Balance availability to others with care for oneself
Reliability, including but not restricted to:
● Accountability / complete tasks
● Punctuality
● Take responsibility
● Organized
Commitment to autonomous maintenance and continuous improvement of competence in:
● Self. Including but not restricted to:
Reflectiveness, personal awareness, and selfassessment
Seek and respond to feedback. Respond to error.
Recognize limits
Lifelong learning
Deal with uncertainty
● Others. Including but not restricted to:
Provide feedback / teaching
People management
Leadership
● Systems. Including but not restricted to:
Advocacy
Seek and respond to results of an audit
Advance knowledge
* The initial literature search was conducted within MEDLINE for articles published from 1996 to 2007 and was
significantly supplemented by references for additional publications.
일부 용어는 명확한 설명이 필요한 것으로 나타났습니다. 첫 번째는 "자기 조절"이었습니다. 전문직의 자기규제는 개인 차원에서의 자기 규제 이상의 의미를 지닙니다. 이 보고서의 초점인 개인 수준에서, 우리는 "자기 규제"라는 용어는 현상 유지를 의미하는 것으로 해석 될 수 있기 때문에 충분히 명확하지 않다고 생각합니다. 대신에 우리는 "자율적 인 유지 관리와 역량의 지속적인 개선"이라는 용어를 선택했습니다. 우리는이 개념을 자신과 다른 사람, 그리고 하나의 시스템이 포함되도록 확장했습니다.
Some terms arose that required clarification. The first was “self- regulation,” Self-regulation of a profession has implications beyond self-regulation at an individual level. At the level of the individual, which is the focus of this report, we believe the term“self- regulation” to be insufficiently explicit because it could be interpreted as meaning preserving the status quo. Instead, we have chosen the term“commitment to autonomous maintenance and continuous improvement of competence.” We have further expanded this concept to include oneself, others, and the systems in which one works.
두 번째 임기는 "이타주의"였는데, 종종 다른 사람들을 위해 자신을 희생한다는 의미로 사용되었지만, 이는 건강한 일과 삶의 균형을 유지하는 것과는 반대이다. 그러므로 우리는 "자신을 돌보면서 동시에 다른 사람들에게도 도움이 될 수 있는 균형감"이라는 개념을 채택했습니다.이 개념은 환자와의 관계 뿐만 아니라 동료와의 관계에서도 발생했기 때문에 환자와 동료에게 초점을 맞추는 두 가지 주제에 각각 배치했습니다.
The second term was “altruism,” which was sometimes inferred as meaning subjugating oneself for others, yet this contrasted with maintaining a healthy work–life balance. We have therefore adopted the concept, “Balance availability to others with care for oneself.” This concept arose in relation to patients but also in relation to colleagues, so we have placed it within each of the two themes that focus on patients and on colleagues, respectively.
세 번째 임기는 "성숙"이었습니다. 우리는 이것을 정의하기가 어려웠으며 그것이 독립적 인 평가 가능한 실체로 분류 될 수 있다고 확신하지 못했습니다.
The third term was “maturity,” We found this difficult to define and were not convinced it could be classified into a separate, assessable entity on its own.
넷째로, 프로페셔널리즘에는 객관식 문제와 같은 전통적인 지식 테스트로 평가할 수있는 자체적 지식 기반이 있습니다. 그러나 주로 전문성은 "아는 것"보다 "하는 것"에 관한 것입니다. 청사진을 개발할 때 우리는 기반 지식 기반을 무시하기를 원하지 않았지만 대신에 Miller's22 피라미드에서 높은 단계를 강조하기를 원했습니다. 즉 "doing을 향해야 하며, "knowing"을 벗어나야 한다.
Fourth, professionalism has its own underpinning base of knowledge that can be assessed with traditional knowledge tests, such as multiple-choice questions. Predominantly, however, professionalism is about what someone does, rather than what he or she knows. In developing a blueprint, we did not wish to ignore the underpinning knowledge base20,21 but, instead, wished to place our emphasis higher on Miller’s22 pyramid; that is, toward “doing” and away from just “knowing.”
마지막으로, 일부 정의에는 환자의 가족에게 정보를 제공하는 것이 포함됩니다. 가족이라는 개념은 사람들마다 다른 의미를 가지므로 "환자에게 중요한 사람들"이라는 구를 선호했습니다.
Finally, some definitions include ensuring that a patient’s family are well informed. The concept of family has different meanings for different people, so we preferred the phrase “people who are important to the patient.”
거의 모든 전문성 정의에는 reflectiveness와 자기 감시의 일부 요소가 포함되었습니다.
Nearly all definitions of professionalism included some element of reflectiveness and/or self-monitoring.
평가 도구
Identification of assessment tools
Table 2
Assessment of an observed clinical encounter.
Mini-CEX는 15~30분동안 환자-의사 상호작용 관찰하고 스냅숏
The mini-CEX is an example of this type of assessment tool.23–26 This tool is used to assess a 15- to 30-minute observed snapshot of a doctor/patient interaction that is conducted within actual patient-care settings using real patients and that has a structured marking sheet that covers predefined generic areas.
Validity derives from using authentic interactions, and
reliability is achieved by ensuring aggregation of multiple assessments and multiple assessors.
Standardization between sites can be achieved with examiner training and by collating scores from several encounters.
The original mini-CEX asks for assessment of professionalism as a single global entity. Modifications to this have been made to look at specific aspects of professionalism through the development of the Professionalism Mini-Evaluation Exercise (P-MEX),27 which can assess four discrete areas: doctor–patient relationship skills, reflective skills, time management, and interprofessional relationship skills.
Collated views of coworkers.
10~20명의 관찰자로부터 평가받음
This is usually achieved through multisource feedback (MSF), which is the systematic collection and feedback of data on an individual’s performance, acquired from a number of stakeholders. In the past, this has sometimes been referred to as 360- degree assessment.24,28–34 Typically, the person being assessed nominates 10 to 20 assessors who collectively can comment on the specified range of that person’s abilities. The assessors may include supervising consultants, registrars, nurses, allied health professionals, and clerical staff.
MSF는 공식적인 평가 조건 내에서 평가하기 어려운 작업장 내에서 실제 행동을 평가하는 데 사용할 수 있습니다
MSF can be used to assess actual behaviors within the workplace that are difficult to assess within formal assessment conditions. It can be used to assess skills and behaviors that can sometimes be concealed within a formal assessment.
Record of incidents of unprofessionalism.
그때그때 필요할 때 사용
This is used on an “as-required” basis whereby an observed incident of unprofessional behavior can be reported and collated centrally. An overview group would look at the reports to determine whether a pattern of behavior is apparent and/or whether further action is needed.35,36
Critical incident report.
프로페셔널리즘에 대한 성찰과 관심을 유도.
This method asks the doctor to reflect on a critical incident he or she has experienced or witnessed.37–39 Because the incident is self-identified, it contrasts with a record of an incident of unprofessionalism described above. It can encourage reflection and attention to elements of professionalism, but it is dependent on the type of incident to determine which aspect of professionalism is being assessed.
Simulation.
Simulations are contrived scenarios that resemble real-life situations but that usually use models or simulated patients.33,40 Sometimes, these can be incorporated within an objective structured clinical examination (OSCE).33 Simulations can be used to assess rare or unpredictable situations or to standardize assessment of higher-order communication skills. Because they are conducted within an artificial context, this can reduce validity, although many “high-fidelity” simulations can be very realistic. They can be useful in assessing how well someone works under pressure. Single simulations, like single OSCE stations,41 can be unreliable.
Paper-based test.
This requires provision of a scenario, such as an ethical dilemma or video encounter, and a series of questions to be answered.42 It can test underlying knowledge of some principles of professionalism, moral reasoning or decision making, and what should be done, but it cannot assess what a candidate actually might do in practice.
Patients’ opinions.
공식적 평가상황에서는 쉽게 관찰하기 어려운 행동의 평가
This is usually obtained by collating questionnaire- based opinions of patients about the nominated person’s abilities in specified areas.33,43–46 It can be used to assess actual behaviors within the workplace that are difficult to assess within formal assessment conditions. It is a direct survey of the key stakeholders of a health service.
환자들은 더 비판적인 편. 따라서 다른 평가와 함께 조합하여 해석해야 함.
However, as discussed later, some patient populations can be more critical than others, so interpretation of results should be in conjunction with other assessments and with an understanding of the population that has been surveyed.
Global view of supervisor.
한 사람이 한 번 관찰 한 것은 신뢰도 낮음.
This is a summary view, usually by a supervisor, reported on a form with predefined criteria. The criteria help to define the areas of importance, but the tendency for them to be used as views of single observers at single points in time can make them unreliable and difficult to defend,47 despite demonstrations of internal consistency.
하지만 여러 상황에 걸쳐서 반복적으로 자료가 수집된다면 평가 근거가 됨
However, such a summary can be useful if it is used repeatedly over time and if it draws on the evidence derived from other assessments.
여러 평가자의 평가결과를 종합하면 MSF와 같음. 따라서 이것은 그 자체가 평가도구라기보다는 총괄평가를 보고하는 수단과 같다.
If multiple raters are used and the results are collated, then it functions like multisource feedback. We have therefore taken the view that it is not an assessment instrument in itself but more a means to report a summary of assessments. For these reasons, we have not included this in our blueprint as an assessment tool, but we acknowledge that it can have an important role in a programmatic assessment process.
Self-administered rating scale.
성찰을 도와주긴 하나, 총괄평가 목적으로는 부적절
This is a questionnaire-based tool that an individual uses to assess his or her personal attributes or attitudes. It can aid reflection, but it has limited use in summative assessments, because it cannot assess what a person actually does.
평가 블루프린트
Assessment blueprint
critical incident report는 블루프린트에 없다.
The overall blueprint is shown in Table 3. Note that critical incident report is not on the blueprint, because the areas it maps against would be individual and idiosyncratic.
가장 좋은 평가 방법은...
If we take the view that the best assessments are ones of
direct observation of the behaviors of interest,
then the mini-CEX,23–26 and particularly the P-MEX,27 would be core components of an assessment program.
관찰되고있다는 것을 알면 행동을 숨길 수 있으므로, MSF와 환자설문을 통해서 보완할 수 있다
Some behaviors can be concealed if a person knows that he or she is being directly observed, so the collated views of coworkers (MSF) and of patients (patient opinion surveys) become complementary sources of information.
도덕적 추론은 시뮬레이션이나, 페이퍼-기반 시나리오
Moral reasoning could be assessed by a simulation or, more efficiently, by a paper-based scenario.
Discussion
블루프린트는 신뢰할 수 있고, 타당하며, 실현 가능한 방식으로 여러 측면을 포착하기 때문에 직접 관측 (미니 CEX23-26 및 P-MEX27을 통해)과 합해진 관점collated view (MSF 및 환자의 의견)가 중요한 요소임을 입증합니다. 한때, 환자의 의견을 모든 것에 대한 척도로 사용하는 것에 대해서 의학분야는 상당히 방어적이었는데, 그 이유는 외적 요인이 환자가 의사를 어떻게 보는지에 영향을 준다고 보았기 때문이다. 예를 들어, 의사는 환자의 요구를 항상 받아 들여서는 안되지만, 그렇지 않으면 환자에게 불리한 평가를 받을 수 있습니다.
The blueprint demonstrates that direct observations (through the mini-CEX23–26 and P-MEX27) and collated views (through MSF and patients’ opinions) are crucial elements because they capture many aspects in reliable, valid, and feasible ways. Medicine has, at times, been rather defensive about using patients’ opinions as a measure of anything, arguing that external factors might have a significant impact on how a patient views his or her doctor. Doctors, for example, do not and should not always acquiesce to patients’ demands, yet failure to do so could result in unfavorable ratings from that patient.
때로는 메시지와 메신져가 서로 혼동되기도 해서, 환자들은 의사가 한 말이 불쾌할 경우 의사에게 낮은 평가를 내리기도 한다. 그러나 반대로, 환자는 우리의 직업이 존재하는 이유이며, 가장 중요한 이해 관계자이며, 자신의 말을 경청하는 것을 감사해한다. 어떤 도구도 단독으로는 의사의 프로페셔널리즘을 측정 할 수 없듯이, 환자 의견도 마찬가지이다. 그러나 환자의 의견은 다른 정보 출처를 보완해줄 수 있으며, 블루프린트에서도 환자의 의견이 중요한 gap을 채워줌을 보여준다.
The message and the messenger can sometimes be confused so that doctors might receive poor ratings if the messages they bring are unpalatable. In contrast, patients are the reason for our profession to exist, are the most important stakeholders, and appreciate having their views heard. Just as any instrument in isolation cannot measure a doctor’s professionalism, so too can patients’ opinions be misleading if taken on their own. However, patients’ opinions do complement other sources of information, and the blueprint shows they fill an important gap.
포트폴리오는 종종 전문성을 평가할 수있는 수단으로 제시되어왔다. 포트폴리오의 기능은 다양한 출처의 데이터를 근거의 body로서 통합하는 것이다. 따라서 포트폴리오의 가치는 어떤 데이터가 수집되느냐에 달려있다. 프로페셔널리즘의 몇 가지 요소로만 제한된 자료를 가지고는 불완전한 그림만을 얻게 된다. 또한 [구조화된 도구]와 [글로벌 판단]이 결합되어 근거를 형성한다. 충분한 수의 관측자와 관찰자의 데이터가 합쳐지면 두 방법 모두 신뢰할 만하다. 따라서 블루프린트에 기반한 체계적인 증거 수집이 필요하다. 그럼에도 불구하고, 프로페셔널리즘의 whole는 부분의 합보다 크고, 모든 요소에 대하여 overview를 보아야 할 필요가 있습니다. 따라서 포트폴리오는 증거를 수집-분석하는 데 중요한 역할을하지만, 그 근거의 출처는 아니다.
Portfolios have often been suggested as a means to assess professionalism.49 The function of a portfolio is to collate data from a variety of sources to forma body of evidence.50 Its value is therefore dependent on the contributing data. If the data are restricted to only a few elements of professionalism, then an incomplete picture will be formed. Furthermore, it acknowledges that the evidence will require a combination of global judgments alongside more structured instruments. Both approaches are reliable, provided data from sufficient numbers of observations and observers are aggregated.51,52 This reinforces the need for a systematic collection of evidence based on a blueprint, such as we have produced. Nevertheless, the whole of professionalism is more than the sum of the parts,3 and there is a need to be able to take an overview of all elements. We therefore see the portfolio as having an important role in collating evidence, but not as the source of that evidence.
우리는 Mini-CEX, P-MEX, MSF, 환자 의견, 종이 기반 테스트, 시뮬레이션, 연구 및 교육 활동 척도, 다른 사람의 평가와 비교한 자기 평가의 정밀 조사 등을 사용할 수 있다고 결론 지었다. 포트폴리오는 그러한 평가 프로그램을 지원하는 유용한 수단입니다.
We conclude that professionalism can be assessed using a combination of mini- CEX, P-MEX, MSF, patients’ opinions, paper-based tests, simulations, measures of research and/or teaching activities, and scrutiny of self-assessments compared with assessments by others. A portfolio is a useful means to support such a program of assessment.
측정 영역에서 더 많은 발전이 필요한 속성은 성찰성, 옹호, 평생 학습, 불확실성 처리, 자신을 돌보는 다른 사람과의 가용성 균형, audit 결과를 찾고 이에 대응하는 것입니다. 이러한 속성은 도구 또는 프로세스 개발의 초점이 되어야 한다.
Attributes that require more development in their measurement are reflectiveness, advocacy, lifelong learning, dealing with uncertainty, balancing availability to others with care for oneself, and seeking and responding to results of an audit. These attributes should be the focus of development of tools and/or processes. The few tools that do exist need to be adapted.
Acad Med. 2009 May;84(5):551-8. doi: 10.1097/ACM.0b013e31819fbaa2.
A blueprint to assess professionalism: results of a systematic review.
Author information
- 1
- University of Otago, Christchurch, New Zealand. tim.wilkinson@otago.ac.nz
Abstract
PURPOSE:
METHOD:
RESULTS:
CONCLUSIONS:
- PMID:
- 19704185
- DOI:
- 10.1097/ACM.0b013e31819fbaa2
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