회진상황에서의 교육: 올스타 교수는 어떻게 하는가?(Med Teach, 2017)

회진상황에서의 교육: 올스타 교수는 어떻게 하는가?(Med Teach, 2017)

Attending rounds: What do the all-star teachers do?

Frank W. Merritta, Melissa N. Noblea, Allan V. Prochazkaa,b, Eva M. Aagaarda and Chad R. Stickratha

aUniversity of Colorado School of Medicine, Aurora, CO, USA; bDenver Veterans’ Affairs Medical Center, Denver, CO, USA

도입

Introduction

주치의는 임상 적 추론을 이끌어 내고 시연하고, 신체 검사 및 병력 습득과 같은 기본 기술을 모델링하고, 일반적인 주제 교육에서 관련 저널 기사에 이르기까지 임상 지식을 전달할 수있는 기회를 갖습니다 (Stickrath, Aagaard, et al. 2013).

the attending physician has the opportunity to elicit and demonstrate clinical reasoning, to model basic skills such as physical exam and history taking, and to impart clinical knowledge ranging from general topic teaching to the referencing of relevant journal articles (Stickrath, Aagaard, et al. 2013).

회진이 비효율적으로 진행되면, 길고, 불필요하고, 학습자에게 교육적인 내용이 거의 제공되지 않을 수 있습니다 (Shankel & Mazzaferri 1986; Shulman 외 1992, Elliot & Hickam 1993, Irby 1994b, Williams 외 2008). 더욱이, 대부분의 임상 교사는 주치의 역할을 하는 동안 가르칠 충분한 시간이 없다고보고했다 (Williams 외, 2008; Crumlish et al. 2009). 레지던트의 근무 시간 제한으로 인해 시간 제약이 더욱 커지고, 교육에 의도하지 않은 영향을 미쳤다 (Goitein et al 2005, Harrison & Allen 2006, Reed 외 2008, Roshetsky 외 2013). 지난 20 년 동안 회진 중 교육이 이루어지는 시간은 크게 감소하였으며(Miller 외 1992, Elliot & Hickam 1993, Priest 외 2010), 전통적인 침상 옆 회진시 교육에서 주로 회의실에서 개최되는 컨퍼런스 (Crumlish 외 2009, Priest 외 2010)로 바뀌어갔다. 이러한 변화는 BST가 의학 교육의 기본 요소라고 생각하는 전문 임상 교육자들 사이에서 중요한 관심을 불러 일으켰습니다 (McGee 2014; Peters & Ten Cate 2014).

When conducted ineffectively, rounds can be lengthy, redundant, and provide little educational content for learners (Shankel & Mazzaferri 1986; Shulman et al. 1992; Elliot & Hickam 1993; Irby 1994b; Williams et al. 2008). Moreover, most clinical teachers report not having enough time to teach their teams while attending (Williams et al. 2008; Crumlish et al. 2009). The implementation of resident work hour limitations has led to even greater time constraints and perhaps had unintended effects on education (Goitein et al. 2005; Harrison & Allen 2006; Reed et al. 2008; Roshetsky et al. 2013). Over the last 20 years, there has been a substantial decrease in the amount of time spent on teaching during rounds (Miller et al. 1992; Elliot & Hickam 1993; Priest et al. 2010) as well as a shift from traditional bedside rounding to rounds that are held primarily in conference rooms (Crumlish et al. 2009; Priest et al. 2010). This shift has raised significant concerns among expert clinical educators who feel that bedside teaching is a fundamental component of medical education (McGee 2014; Peters & Ten Cate 2014).

방법

Methods

세팅과 연구 설계

Setting and study design

The present study used both direct observation of a large cohort of attending physicians and an attitudinal assessment of their learners to better understand the characteristics of effective clinical teachers in the current era. We analyzed data from a cross-sectional observational study of general medicine inpatient teams at 4 teaching hospitals affiliated with a large public medical school from July 2010 to March 2012. Initial results and methods from this study have been previously published (Stickrath, Noble, et al. 2013).

자료 수집

Data collection

Fourth-year medical students were trained to accompany teams on rounds, silently and unobtrusively, while observing and recording the frequency and location (bedside, hallway, or conference room) of various activities. Observers used a pre-defined checklist of activities thought to be important during rounds, which was created based on literature review and local expert opinion. The observers used a recorded whether or not each activity was performed for each patient seen during rounds. Th teaching activities included 

(1) 환자 치료 계획에 관한 질문 다루기

(2) 일반적인 의학 주제의 가르침,

(3) 특정 증거 기반 의학 문헌을 검토,

(4) trainee가 학습 이슈로 찾아낸 주제에 대한 교육,

(5) 병력청취 기술 습득,

(6) 신체검사 기술 교육,

(7) 구두발표 기술 교육,

(8) 미래 학습 계획을 논의하고,

(9) 학습자에게 피드백 제공.

• (1) addressing questions about the patient care plan, 

• (2) teaching of general medical topics, 

• (3) reviewing specific evidence-based medicine literature, 

• (4) teaching on a topic that was identified as a learning issue by the trainees, 

• (5) teaching history-taking skills, 

• (6) teaching physical examination skills, 

• (7) teaching oral presentation skills, 

• (8) discussing a future learning plan, and 

• (9) providing feedback to learners.

교육 효과성에 따른 계층화

Stratification by teaching effectiveness

The rounding episodes were divided into three groups based on learner satisfaction as measured by the Likert scale. The scores for each rounding day were averaged across the trainees. The three groups were determined by natural breaks in the distribution of the average scores.

자료 분석

Data analysis

결과

Results

그룹 간 회진시간 차이 없음

There was no significant difference in time spent rounding per patient between these groups (Table 1).

세 가지를 제외하고 회진 당 교육활동 갯수 차이 없음

The frequencies of the remaining teaching activities were not significantly different between groups (Table 2; Figure 1).

세 가지 구체적인 교육활동의 빈도와 전체적인 교육효과성에 유의한 관계

There were positive correlations between the frequency of each of same three specific teaching activities and teaching effectiveness scores, while modeling history taking was modestly correlated with lower scores (Table 3).

고찰

Discussion

첫째, 우리는 호진 교육에 대한 학습자 만족도가 매우 다양하다는 것을 발견했습니다. 학습자의 절반 이상이 교육의 가치를 향상시킬 실질적인 여지가 있음을지지하면서 교육에 만족하지 않았습니다. 가장 낮은 등급의 교사조차도 환자 당 평균 1.5 교습 활동 (또는 반올림 에피소드 당 약 15 회)을 수행했다는 점에서, 모든 교육이 효과적인 교육은 아니다는 개념을 지지한다는 점에 유의해야합니다.

First, we found a wide range of learner satisfaction with teaching on rounds: More than half of the learners were dissatisfied with teaching, supporting the notion that there is substantial room to improve the educational value of rounds. It is important to note that even the lowest-rated teachers still performed an average of 1.5 teaching activities per patient (or about 15 per rounding episode), supports the concept that not all teaching is effective teaching.

사실, 우리는 일군의 최고의 교사가 특정 유형의 가르침을 동료들보다 더 자주 제공하는 것으로 나타났습니다. 여기에는 환자 특정적이고, 학습자 주도 교육 주제, 피드백 제공이다.

In fact, we found that the best teachers in our cohort engaged in certain types of teaching more frequently than their peers, namely patient-specific and leaner-identified teaching topics and providing feedback.

이 모델은 

• 환자 특이적 교육의 중요성, 

• 학습자에 대한 교육 진단 및 타겟팅, 

• 학습자가 식별 한 교육 주제 탐색, 

• 실시간의 구체적인 피드백 제공 

등을 지속적으로 강조해 왔습니다. (Irby Ramani 2003, Gonzalo 외. 2013).

These models have consistently highlighted the importance of 

• patient-specific teaching, 

• diagnosing and targeting teaching to the learner, 

• seeking learner-identified teaching topics, and 

• providing real-time, specific feedback (Irby 1994a; Ramani 2003; Gonzalo et al. 2013).

특정 교육 행동을 더 많이 하는 것 외에도, 최고의 교사는 환자 당 전체적으로는 시간을 덜 쓰면서도, 환자 당 교육 행동은 더 많이 하는 것으로 나타났습니다. 가장 효과적인 교사는 덜 효과적 인 교사 (2.1 대 1.5)보다 환자 당 전체 교육 활동을 약 30 % 더 많이 수행했습니다.

In addition to more frequently engaging in certain teaching behaviors, we found that the best teachers actually engaged in more overall teaching behaviors per patient, while spending slightly less time overall. The most effective teachers performed about 30% more total teaching activities per patient-encounter than their less effective counterparts (2.1 versus 1.5).

우리는 이러한 교사들이 어떻게 시간 효율성을 향상 시켰는지 명확하게 설명하지 못했지만, 우수한 임상 교사는 사전 준비를 통해서 더 효과적으로 회진을 할 수 있다고 이전에 제안되어왔다. (Irby 1992; Kroenke et al. 1997; Ramani 2003; Gonzalo et al. 2013) 또는 여러 활동을 병행하여 수행 할 수 있습니다 (Stickrath, Aagaard, et al. 2013).

While we were unable to delineate this clearly how these teachers achieved enhanced time-efficiency, it has been previously proposed that excellent clinical teachers are able to round more efficiently by preparing substantially in advance (Irby 1992; Kroenke et al. 1997; Ramani 2003; Gonzalo et al. 2013)or by performing multiple activities in parallel (Stickrath, Aagaard, et al. 2013).

Bedside Teaching : 학생과 교사가 환자의 병상에 옆에서 사례를 논의하고 임상 절차를 시연하는 임상 회진의 일부입니다. 주치의가 환자와 어떻게 관련되어 있는지 보고 환자 인터뷰, 신체 검사 및 카운슬링 기술에 대한 직접적인 교육을받을 수있는 기회입니다.

Bedside Teaching: A part of clinical rounds where both student and instructor attends the patient's bedside to discuss the case and/or demonstrate a clinical procedure. This is the student's opportunity to see how the attending physician relates to the patient and to get hands-on instruction in interviewing a patient, physical examination, and counseling skills.

학습자 중심 교육 : 학생들의 요구가 우선시되는 교육 방법. 

• 학습자는 지식 격차를 규명하고, 학습 격차를 줄이기 위해 적극적으로 참여하며, 학습 효과를 추적해야합니다. 

• 교사는 정보를 spoonfed 하듯 제공하는 대신이 과정을 촉진해야합니다. 

이 접근법은 학생들의 학습 동기를 높이고자가 학습과 지속적인 교육을 위해 학생들을 준비시킵니다. 학습자 중심 교육은 교사 중심 교육의 반대입니다.

Learner-Centred Education: A method of teaching in which the students' needs have priority. 

• Learners are responsible for identifying knowledge gaps, actively participating in filling them, and keeping track of their learning gains. 

• Teachers are expected to facilitate this process instead of supplying "spoonfed" information. 

This approach increases the students' motivation to learn and prepares them for self-learning and continuous education. Learner-centered education is the opposite of teacher-centered education.

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Med Teach. 2017 Jan;39(1):100-104. doi: 10.1080/0142159X.2017.1248914. Epub 2016 Nov 12.

Attending rounds: What do the all-star teachers do?

Merritt FW1, Noble MN1, Prochazka AV1,2, Aagaard EM1, Stickrath CR1.

Author information

1

a University of Colorado School of Medicine , Aurora , CO , USA.

2

b Denver Veterans' Affairs Medical Center , Denver , CO , USA.

Abstract

AIM:

To examine differences in the types of teaching activities performed during rounds between the most effective and least effective inpatient teaching attendings.

METHODS:

Participants included 56 attending physicians supervising 279 trainees. Trained observers accompanied teams during roundsand recorded the frequencies of educational activities that occurred. Students and residents then rated their satisfaction with the teaching on rounds.

RESULTS:

Attending physicians with the highest learner satisfaction scores performed significantly more teaching activities per patient than attending physicians who were rated as average or less-effective (2.1 vs. 1.4 vs. 1.5; p = .03). There were significant differences in the frequencies of 3 out of the 9 specific teaching activities observed, including answering specific patient-care related questions (77% vs. 66% vs. 47%; p = .003), teaching on learner chosen topics (8% vs. 2% vs. 2%; p = .02), and providing feedback (31% vs. 10% vs. 0.1%; p = .001).

CONCLUSIONS:

Specific categories of teaching activities-patient-specific teaching, teaching on learner-identified topics, and providing real-time feedback-are performed more frequently by the highest-rated attending physicians, which can guide faculty development.

PMID:

 

27841061

 

DOI:

 

10.1080/0142159X.2017.1248914