레지던트가 교육을 하게 만드는 동기는? 임상교육에 대한 태도 연구(Med Educ, 2016)

레지던트가 교육을 하게 만드는 동기는? 임상교육에 대한 태도 연구(Med Educ, 2016)

What motivates residents to teach? The Attitudes in Clinical Teaching study

Sarah Dotters-Katz,1 Charles W Hargett,2 Aimee K Zaas3 & Lisa G Criscione-Schreiber4

도입

INTRODUCTION

이타적인 이유, 자신을 가르친 선생님으로부터의 영감, 특정 과에 리크루트 되고자하는 욕구 등이 고위 임상의들 사이에서 교육을 하는 내적 동기로 확인되었습니다 .1 동기 부여는 복잡하며, 개인적인 목표와 추진력, 강화 요인 등이 포함된다.1 동기 부여 개인적인 태도와 상호 작용한다. 태도는 우리가 사물이나 개념에 대해 어떻게 느끼고 변화 될 수 있는지에 대한 것입니다 .2 어떤 것에 대한 우호적 태도를 가지면 동기 부여에 영향을 줄 수 있으며, 동기 부여가 높으면 개념이나 활동에 대한 태도에 영향을 줄 수 있습니다 .2

Internal motivations to teach, including altruistic reasons, inspiration from prior teachers and desire to recruit into a specialty, have been identified as motivations to teach among senior clinicians.1 Motivation is complex and includes personal goals and drives as well as reinforcing factors.1 Motivation interacts with personal attitudes; attitudes are how we feel about an object or concept and can be changed.2 Having a favourable attitude to something can affect motivation, and being highly motivated can have an impact on the attitude one has to a concept or activity.2

레지던트 또는 registrar로도 알려져있는 GME trainee는 임상 교육의 중요한 원천입니다. 그들은 의대생의 임상 교육을 최대 85 %까지 제공하는 것으로 추산되며, 그들은 그것의 주요 책임 중 하나라고 생각한다.

Graduate medical trainees, also known as residents or registrars, are a crucial source of clinical teaching; they have been estimated to provide up to 85% of medical students’ clinical teaching and they consider it one of their primary responsibilities.3,4.

교사의 기술을 향상시키기 위해 수없이 많은 RAT (resident-as-teacher) 프로그램이 개발되었으며 이러한 프로그램은 가르침에 대한 레지던트의 지식과 교육에 대한 열정에 긍정적 인 영향을 미쳤다. 6-8 한 연구에서 레지던트들은 RAT프로그램 후에 준비도가 높아졌다고 느꼈고, 자신감이 생겼고, '건강한 불안'을 경험했다.

innumerable resident-as-teacher (RAT) programmes have been developed to improve residents’ teaching skills and such programmes have been shown to favourably impact residents’ knowledge about teaching as well as their enthusiasm for teaching.6–8 In one study, residents felt more preparedness, confident and ‘healthy anxiety’ about teaching after a resident as teacher programme.9

• 컨설턴트 또는 교수진으로도 알려진 주치의 중 교사의 한 가지 주목할만한 연구 결과에 따르면 교사의 1/4이 학생 중심적이며 교육이 재미 있고 학습자 중심이어야하고 교사의 1/4은 성과 지향적이어야 한다고 믿었습니다. 

• 교수자들 사이의 유사한 신념 평가는 3 분의 1 이상이 임상가와 교사로서 강력한 정체성을 포함하는 공통적 인 신념을 공유한다는 것을 발견했다. 이 신념을 가진 교수자들은 [교수법과 교수법 기대감에 대한 낮은 신념을 가진 교수진]보다 더 많은 것을 가르쳤다 .12 

• 다른 연구에서 다수의 교사가 교사 그룹은 교육의 본질적 가치에 대한 긍정적 인 의견을 많이 갖고있는 반면, 소수 교사들은 교육의 즐거움 부족, 교육에 대한 여러 장애요인 등 교육에 대한 부정적 생각을 가지고 있었다.1 

• 작업량이 크다고 느낄수록 교육 시간이 적어졌고, 심지어 고위 임상가조차도 교육과 임상 치료 및 수많은 임상 교육 장벽이 의학 교육 시스템에 존재한다 .13,14

• Among attending physicians, also known as consultants or faculty members, one notable study of beliefs about teaching found that a quarter of teachers were student oriented, believing that teaching should be fun and learner focused, and a quarter were performance oriented, focusing on students’ mastery of content for problem solving.11 

• A similar evaluation of beliefs among faculty members found over a third sharing a common belief profile, including a strong identity as both a clinician and a teacher; individuals with these beliefs taught more than faculty members who shared belief profiles that included lower confidence in their teaching and teaching expectations.12 

• The largest group of medical teachers in another study shared high agreement with positive statements about the intrinsic value of teaching, whereas a small number of faculty members were more aligned with negative statements about teaching, including lack of enjoyment of teaching and excessive barriers to teaching.1 

• A greater perceived workload has been associated with decreased time for teaching and even senior clinicians struggle with the competing demands of education and clinical care, and numerous barriers to clinical teaching exist in the medical education system.13,14

레지던트는 교수들과 비슷한 시간 및 직장 관련 장벽을 경험할 수 있지만, 동기와 태도는 중요한 방식으로 다를 수 있습니다. 특히, 레지던트는 학습자와 교사 모두의 이중 역할을 navigate해야 합니다. 교수진과 비교하여 레지던트들은 학습 우선 순위가 다르며, 시간에 따라 요구 사항이 다르며, 교수진보다 동기 부여가 다를 수 있습니다 .15,16 또한 근무 시간 규정에 따라 의사 내과의 교육 및 학습 기회가 제한 될 수 있습니다.

While residents may experience similar time and workplace-related barriers to those of faculty teachers, their motivation for and attitudes towards teaching may differ in important ways. Notably, residents must navigate the dual roles of both learner and teacher. Compared with faculty members, residents have different learning priorities, different demands on their time and are likely to have different motivations for teaching than do faculty members.15,16 Additionally, duty-hours regulations may limit teaching and learning opportunities for doctors-intraining.

따라서 우리는 태도를 연구하는 데 사용되는 기술인 Q 방법을 사용하여 의학 문학의 이러한 격차를 해소하고 교습에 대한 비슷한 태도를 공유하는 거주자 그룹을 정의하고자했습니다. Q 방법론은 건강 관련 질문과 태도를 연구하기 위해 널리 사용되어왔다 .18-20

Thus, we aimed to address this gap in the medical literature by using Q methodology, a technique used to study sets of attitudes, to define groups of residents who shared similar attitudes towards teaching. Q methodology has been widely used to study health-related questions and attitudes.18–20

방법

METHODS

As is typical for Q methodology research, our study was conducted in three steps.22 

• The first step was developing a set of statements for participants to rank order. 

• The second step was identifying potential subjects and administering the Q-sort survey. 

• The third step involved analysis and interpretation. 

These steps are described below in more detail.

Statement set

We first performed a literature search using PubMed, which combined two literature sets; the first used any combination of resident, fellows, trainees or resident as teacher and the second included motivation, attitudes, education and teacher.

The study authors, through a process of independent analysis and then subsequent mutual negotiation and discussion, narrowed this list to 47 statements (the number needed for this Q-sort) by combining duplicates and merging statements that were very similar in nature or had synonymous meanings.

Subjects and sorting

Q-sorts were administered online with the open source program FlashQ (Hackert & Braehler, 2007). Following an introduction with instructions, each participant was shown all 47 teaching statements in a random order and asked to sort the cards based on their attitude towards their role as a clinical teacher.

Respondents to the Q-sort could elect to enter demographic data, including gender, year of training, training classification (resident vs. fellow), medical specialty, previous training in education and plans to teach after culmination of medical training.

Data analysis

Individuals’ rankings of the Q set were analysed using by-person factor analysis to calculate correlations between individuals’ viewpoints. Factor analysis followed by varimax rotation was conducted to identify clusters of respondents whose Q-sorts were highly correlated with each other and uncorrelated with other participants (i.e. people with similar views share the same factor). The best factor solution was identified based on both objective criteria and interpretability. Each factor was defined by at least two non-confounded Q-sorts. 

The KaiserGuttman criterion, Humphrey’s rule and the screen test were used to guide factor inclusion.23 Factors are defined as groups of individuals with similar opinions, feelings and views in relation to the subject being studied. To be isolated as a factor, a group must have at least two individuals within it. We performed iterative analyses, independently interpreted the defining characteristic attitudes within each factor, and by consensus decided that the three-factor analysis best identified distinct attitudinal groups. For this analysis, a Z-score is defined as the weighted normalised average score for a specific statement based on all of the respondents within that factor. A p-value of less than 0.05 was considered significant. Demographic data were analysed using descriptive statistics.

RESULTS

Analysis of participants’ Q-sorts resulted in a three factor solution, with each factor representing a distinct group of attitudes towards teaching in the clinical setting. Our representative one-word descriptions of these attitudinal groups was: enthusiasm, reluctance and rewarded.

요인1: 열정

Factor 1: enthusiasm

요인 1로 분류 된 훈련생은 임상 교육에 대한 열정 (진술 # 5, +5)으로 정의됩니다. 열정적 인 교사는 학습자가 훌륭한 의사가되는 것이 중요하기 때문에 시간을두고 교육에 전념합니다 (진술 # 39, +3, 14, +3). 친구들과 비교했을 때, 그들은 일반적으로 자신감이 있으며 (진술 # 43, +1) 가르치기 위해 준비했습니다. 열정적 인 교사는 시간 (진술 # 37, 1, # 38, 2, # 41, 2, # 40,2)과 사회적 기대 또는 피드백 (진술 8, 1, # 28, 0)과 같은 외부 압력에 상대적으로 무관심하다. .

Trainees who were sorted into factor 1 are defined by feeling enthusiasm (statement #5, +5) for clinical teaching. Enthusiastic teachers make time for and are committed to teaching because it is important to them that learners become good doctors (statements #39, +3; 14, +3). Compared with their peers, they generally feel confident (statement #43, +1) and prepared to teach. Enthusiastic teachers are relatively indifferent to external pressures such as time (statements #37, 1; #38,  2; #41,  2; #40,  2) and social expectation or feedback (statements #8,  1; #28, 0).

마지막으로 '나는 두 가지 기본 원칙에 따라 가르친다 : (i) 열정은 전염성이 있고 (ii) 레지던트는 의대생의 직업 선택에 가장 큰 영향을 미친다'.

Finally, ‘I teach based on two guiding principles: (i) enthusiasm is contagious and (ii) residents are the single largest influence on medical student career choices’.

요인2: 주저함

Factor 2: reluctance

소극적 인 교사들은 가르치는 것은 중요하며 (성명서 # 1, +2), 학습자와의 상호 작용을 즐긴다 (진술 # 6, +3), 자신의 의무에 압도 당하고, 긍정적인 인센티브를 느끼지 못한다. 마지 못해하는 태도를 가진 사람들은 그들의 임상 업무량 (진술 문 # 37, +5)과 근무 시간 (진술 문 # 40, 2)에 의해 교수법이 제한된다고 생각합니다. 마지 못해하는 교사들은 교사로서 요구받는 기대에 대해 잘 알지 못하며 가르 칠 준비가 되어있지 않다고 느낍니다. 이러한 교사들은 학습자의 관심 수준 (진술 # 31, +1)에 더 많은 영향을 받으며, 교육에서 좌절을 느낄 가능성이 더 높다

Reluctant teachers feel that teaching is important (statement #1, +2) and enjoy the interaction with the learner (statement #6, +3), but also feel overwhelmed by their duties and perceive little in the way of positive incentives to teach. Individuals with a reluctant attitude feel their teaching is limited by their clinical workload (statement #37, +5) and duty hours (statement #40, 2). Reluctant teachers are less aware of their expectations as a teacher and feel the least prepared to teach. Compared with their peers, reluctant teachers are more influenced by their learners’ level of interest (statement #31, +1) and more ment #33,likely 2).to feel frustrated with teaching (state-

'마지 못해 교사'연수생의 경우, 임상 교육의 노력은 직접적인 인센티브를 거의 갖지 못했지만, 교육에 시간을 쓸 가치가 없다는 것에는 매우 강력하게 반대했다 (진술 # 36, # 5). 이 그룹에서 가르치는 활동은 감사와 존경의 느낌을 가져 오지 않으며 (진술 # 2, # 1, # 28, # 1) 또는 전문적인 인정으로 이끄는 것은 아닙니다 (진술 # 25, # 2, # 27, # 4 ). 교수법은 의견을 표현하기위한 출구로 간주되지 않습니다 (진술 문 # 23, # 2).

For ‘reluctant teacher’ trainees, the effort of clinical teaching had little direct incentive, although they very strongly disagreed that teaching was not worth their time (statement #36,
5). In this group, the activity of teaching doesn’t bring about feelings of appreciation and respect (statements #2,
1; #28,
1) or lead to professional recognition (statements # 25,
2; #27,
4). Teaching is not viewed as an outlet for expressing opinions (statement #23,
2).

이 요소에서 연수생이 느낀 가르침을 둘러싼 스트레스는 '나는 내 공부에 쓸 시간이없고, 다른 사람에게 가르치는데 쓸 시간은 더 없다'는 진술에 예시되어있다.

the stress surrounding teaching felt by trainees in this factor is exemplified in this statement: ‘I do not have time to spend to learn the material, much less teach it to another person’.

요인3: 보상받음

Factor 3: rewarded

보상받는 교사들은 가르침의 목표-지향적 장점에 대해 더 많은 의견을 나눕니다. 이 그룹에서는 개인의 강점과 약점에 대한 통찰력을 제공하고 의사 소통 기술을 향상 시키며 (문 제 20, 4) 최신 문헌을 알 수 있는 상태로 유지합니다 (진술 문 # 22, +2). 보상을받은 교사는 교육 역할을 기대받을 것으로 느낄 가능성이 가장 높으며 가르칠 때 존경받습니다 (문 # 28, +3). 이 그룹은 또한 자신의 전문 분야가 의학 교육과 관련이 있음을 가장 강력하게 동의했습니다 (진술 문 # 13, +5).

Rewarded teachers share agreement with more of the goal-directed benefits of teaching. For this group, teaching provides insight into personal strengths and weaknesses (statement #24, +5), improves communication skills (statement #20, +4) and keeps teachers up to date on the literature (statement #22, +2). Rewarded teachers are the most likely to feel expected to teach (statement #8, +2) and respected when they do teach (statement #28, +3). This group also agreed the most strongly that their specialty is relevant to medical education (statement #13, +5).

기관이 교육에 가치를 둔다는 것에 대한 매우 강한 믿음을 감안할 때, 보상받은 교사는 기관 또는 프로그램과 alignment에 관련된 기대와 보상을 느끼게됩니다. 그들의 동료들에 비해, 보상받은 교사들은 그들의 프로그램이 가르침을 위해 훈련생을 인정하고 보상한다고 느낍니다. (진술 문 # 23, 0) 이들은 부서에서 그들에게 교육을 하라고 했기 때문에 가르치는 것이며, 그들 자신의 교사들로부터 영감을 받았기 때문이 아니다(진술서 # 17, 1). 보상받는 교사는 학습자와의 상호 작용을 즐기지 않으며 (제 6 항, 제 2 항), 학습자가 노력하지 않고도 적절한 가르침을받는다고 느끼기 쉽습니다 (진술 # 35, 0). 이들이 특별히 가르침에 열정이 있다거나, 헌신적인 것은 아니다.이들에게 가르침이 직무 만족도를 향상시키지 않습니다 (성명서 # 4, 0). 이들은 근무 시간으로 인해 제한받는 느낌이 가장 적습니다 (진술 문 # 40, 5).

Given their very strong belief that the institution values teaching (statement #11, +4), rewarded teachers feel expectations and rewards related to institutional or programme alignment. Relative to their peers, rewarded teachers feel that their programme recognises and rewards trainees for teaching (statement #23, 0) and are more likely to teach because their department or division asks them to (statement #10,
2), not because they’ve been inspired by their own teachers (statement #17, 1). Rewarded teachers do not enjoy the interaction with learners (statement #6,
2) and are more likely to feel that learners receive adequate teaching without their efforts (statement #35, 0). They are not particularly enthusiastic about (statement #5, 0) or committed to (statement #3,
1) teaching, nor does teaching improve their job satisfaction (statement #4, 0). Rewarded teachers were the least likely to feel limited by duty hours (statement #40,
5).

'나는 교육을 준비하면서 많은 것을 배웠다.' '교육에 필요한 시간을 보호해주는 것을 강조하는 분위기가 있다'

‘I learn a lot in reviewing for teaching’. ‘There is emphasis placed on protected time for teaching’

다른 요인들과 크게 대조적으로이 그룹의 개인들로부터 근무 시간이 가르침에 영향을 미치지 않는다는 15 개의 의견이있었습니다.

In striking contrast to the other factors, there were 15 comments from individuals in this group specifically stating that duty hours did not affect teaching.

고찰

DISCUSSION

가장 큰 그룹의 연수생은 우리가 '열정적 인 교사'라고 묘사 한 요소로 분리되었습니다. 참여한 연수생의 절반 이상을 포함하는 이 집단은 긍정적 인 태도와 가르침에 대한 동기 부여를 공유함으로써 장벽이 있음에도 불구하고 가르 칠 가능성이 높습니다.

The largest group of trainees segregated into a factor we described as ‘enthusiastic teachers’. This cluster, which included over half of participating trainees, shared both positive attitudes towards and motivation to engage in teaching, making it highly likely these individuals will teach despite potential barriers.

RAT 프로그램이 '열정적 인 교사'를 목표로 삼을 때에는, 태도를 바꾸거나 가르치는 동기 부여를 시도하는 것이 아니라, 교사의 기술 향상에 집중해야 한다.

Targeting ‘enthusiastic teachers’ for RAT programmes does not mean trying to change their attitudes or provide motivation to teach, but rather might be able to focus on improving teaching skills.

우리가 확인한 두 번째 그룹 인 '마지 못해 하는 교사'는 그룹이 무엇을 어떻게 가르치고 강하게 식별하는지에 대해 불확실해하며, 임상 업무 요구가 교육의 장애 요인이라고 강력하게 이야기한다.

The second group we identified, the ‘reluctant teachers’, as a group endorse uncertainty regarding what and how to teach and strongly identify with statements identifying barriers to teaching based on clinical work demands.

열정적 인 교사 들과는 대조적으로,이 그룹의 연수생들은 가르치기위한 동기가 낮으며, 다른 요구에 시간과 노력을 소비한다. Early trainee중에 이러한 태도를 가진 레지던트가 많았으며, 이는 교육 및 시간 관리에 대한 불안감과 일치합니다.

By contrast with the enthusiastic teachers, trainees in this group have a low motivation to teach, being consumed by other demands on their time and efforts. This attitudinal group was highly populated by early trainees, which is consistent with insecurity in teaching and time management concerns.

교수진의 동기와 태도에 대한 연구에서는 이러한 집단이 확인되지 않았다. 이 그룹의 구성원들은 교육에 동기부여가 되어있지는 않지만, 전반적으로 교육에 대한 긍정적 태도를 가지고 있었다. 교육에 대한 태도는 긍정적이지만 동기부여가 낮은 연수생들에 대해서는 교육 동기를 향상시키기 위해 교육의 장벽 (방향 부족, 준비 및 기술 부족)을 해결하는 데 초점을 맞출 수 있습니다.

This population has not been identified in studies looking at faculty members’ motivation for and attitudes toward teaching.1,12 Despite not having the motivation to teach, members of this attitudinal group endorsed overall positive attitudes about teaching. In trainees with positive attitudes towards teaching but low motivation based on perceived barriers, efforts could focus on addressing barriers to teaching (such as lack of direction, preparation and skill) in order to improve the motivation to teach.

'마지못해 하는' 레지던트들은, 지식, 기술, 태도 등 무엇이 되었든, 교육 과정의 특정 부분에서 무엇을 다뤄야 하는지에 대해 명확한 지시와 요구를 내려야 할 것이다.

trainees in this group would benefit from clear instructions and expectations from faculty members regarding what to teach, perhaps responding to requests to address specific parts of the curriculum, whether knowledge, skills or attitudes.

우리가 확인한 마지막 하우스 직원 그룹은 '보상받은 레지던트'로 분류되며, 그들이 가르치는 것에서 얻는 보상과 인정에서 만족을 얻습니다. 즉,이 그룹의 구성원은 가르치는 동기가 부여됩니다. 이 집단의 훈련생은 이전 연구에서 밝혀지지 않았으며, 여러 학과 교수들에게서도 공통적으로 발견된다 .1,14,24 외부 보상은 이 집단을 가르치도록 동기를 부여하지만 일반적으로 가르침에 대한 부정적인 태도를 공유했다. 따라서이 그룹의 교수법을 향상시키기 위해 노력은 교수법에 대한 긍정적 인 태도 개발에 집중할 수 있습니다.

The final group of house staff we identified is categorised as ‘rewarded’, and they derive satisfaction from the rewards and recognition they get from teaching. In other words, members of this group are motivated to teach. This group of trainees has not been identified in previous studies and this subset is commonly identified at the faculty level across disciplines.1,14,24 Although external rewards motivate this group to teach, they generally shared negative attitudes towards teaching. Thus, to improve teaching in this group, efforts could focus on developing positive attitudes about teaching.

이 연구에서 전반적인 응답률은 낮지 만 총 107 명의 연수생이 설문 조사를 완료했으며 Q-sort 방법론은 통계적 유의미성을 얻기 위해 큰 숫자가 필요하지 않습니다.

Though the overall response rate in this study was low, a total of 107 trainees completed the survey, and Q-sort methodology does not require large numbers to reach statistical significance.

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Med Educ. 2016 Jul;50(7):768-77. doi: 10.1111/medu.13075.

What motivates residents to teach? The Attitudes in Clinical Teaching study.

Dotters-Katz S1, Hargett CW2, Zaas AK3, Criscione-Schreiber LG4.

Author information

1

Division of Maternal Fetal Medicine, University of North Carolina, Chapel Hill, North Carolina, USA.

2

Division of Pulmonary, Allergy, and Critical Care Medicine, Duke University Medical Center, Durham, North Carolina, USA.

3

Division of Infectious Diseases, Duke University Medical Center, Durham, North Carolina, USA.

4

Division of Rheumatology and Immunology, Duke University Medical Center, Durham, North Carolina, USA.

Abstract

CONTEXT:

Graduate medical trainees have a critical role in the teaching of other trainees. Improving their teaching requires an understanding of their attitudes towards teaching and their motivation to teach. Both have been incompletely explored in this population. We aimed to better understand graduate medical trainees' attitudes towards teaching and motivation to teach in the clinical setting in order to inform modifications to resident-as-teacher (RAT) programmes and enhance teaching practices.

METHODS:

We applied Q methodology, an established sorting method, to identify and quantify the factors that have an impact on trainees' engagement in teaching. We invited house officers at our institution to rank-order 47 statements regarding their attitudes to and motivation for teaching. Respondents explained their Q-sort rankings in writing and completed a demographic questionnaire. By-person factor analysis yielded groups of individuals with similar attitudes.

RESULTS:

One hundred and seven trainees completed the Q-sort. We found three primary groups of attitudes towards teaching in the clinicalsetting: enthusiasm, reluctance and rewarded. Enthusiastic teachers are committed and make time to teach. Teaching increases their job satisfaction. Reluctant teachers have enthusiasm but are earlier in training and feel limited by clinical workload and unprepared. Rewarded teachers feel teaching is worthwhile and derive satisfaction from the rewards and recognition they receive for teaching.

CONCLUSIONS:

This improved understanding of common attitudes shared by groups of residents will help curriculum designers create RAT programmes to further reinforce and encourage attitudes that promote teaching as well as improve trainees' motivation to teach. Designing RAT programmes that acknowledge the attitudes to and motivations for teaching should help develop effective teachers to improve educational outcomes. Directed efforts to enhance motivation for reluctant teachers and encourage more positive attitudes in rewarded teachers may lead to improved teaching behaviours among residents.

© 2016 John Wiley & Sons Ltd.

PMID:

 

27295481

 

DOI:

 

10.1111/medu.13075

[Indexed for MEDLINE]