잠재교육과정의 어떤 경험이 학생들에게 프로페셔널리즘에 대하여 가르쳐주는가? (Acad Med, 2011)

잠재교육과정의 어떤 경험이 학생들에게 프로페셔널리즘에 대하여 가르쳐주는가? (Acad Med, 2011)

Which Experiences in the Hidden Curriculum Teach Students About Professionalism?

Orit Karnieli-Miller, PhD, T. Robert Vu, MD, Richard M. Frankel, PhD, Matthew C. Holtman, PhD, Stephen G. Clyman, MD, Siu L. Hui, PhD, and Thomas S. Inui, MD, ScM

최근 몇 년 동안, 다양한 형태의 내러티브 적 서술과 성찰이 전문성 개발을 향상시키고 전문직업적인 가치를 가르치기 위해 광범위하게 사용되었습니다 .1-4 학생 서사를 사용하는 rationale는 [비공식적 인 또는 "숨겨진"교과 과정에 대한 학생들의 생생한 경험과 일상적인 immersion이 전문성 발달에 강력한 영향을 미친다는 것]이다.5-7 이러한 경험은 조직의 규범 및 의식에 대한 학생의 사회화에 영향을주고, 학생과 교사, 환자 및 의사 간의 대인 관계적 관례convention을 가르치고, 다른 전문가들과의 관계의 복잡성을 보여줍니다 .8

In recent years, narrative writing and reflection in various forms have been widely used to enhance professional development and inculcate professional values.1–4 The rationale for using student narratives is a belief that the lived experience of students and their day-to- day immersion in this informal or “hidden” curriculum are a powerful influence on their professional development.5–7 These experiences influence students’ socialization into the norms and rituals of the organization, teach the conventions of interpersonal processes between students and teachers and patients and physicians, and demonstrate the complexities of relationships with other professionals.8

부정적인 역할 모델링에 노출되면 냉소적으로되고 부정적인 전문직업적 태도와 행동을 채택 할 가능성이 높아질 수 있습니다 .10 성찰적인 글쓰기와 피드백은 이러한 위험을 완화 할 수 있습니다. 많은 경험 중에서 하나의 경험을 선택하는 것은 분별discernment적 행동으로 묘사 될 수 있습니다 .11

Exposure to negative role modeling, may increase the likelihood of becoming cynical and adopting negative professional attitudes and behaviors.10 Reflective writing and feedback may mitigate this risk. Selecting one experience from among many could be described as an act of discernment.11

본 연구는 의과 대학생들의 숨겨진 커리큘럼에서의 학습 경험과 이들 경험이 전문성과 관련된 범주에 속하는 방법 사이의 관계를 조사하는데 초점을 맞추고있다.

The present study focuses on examining the relationship between medical students’ learning experiences in the hidden curriculum and how they attribute these experiences to the categories associated with professionalism.

Method

Many terms, definitions, and taxonomies of professionalism are available in the broad-ranging literature that describe the attributes of the “good” physician, professional values, professional ethics, and commitments of medicine.5,21–23 One taxonomy that might be considered a reasonable gold standard emerged from a working conference cosponsored by the AAMC and NBME.20 The qualities of the good physician in this formulation were captured in eight categories: 

• (1) altruism, 

• (2) responsibility and accountability, 

• (3) excellence and scholarship, 

• (4) respect, 

• (5) honor and integrity, 

• (6) caring/compassion/communication, 

• (7) leadership, and 

• (8) knowledge and skills.

학생 서사

The student narratives

Since February 2004, third-year IUSM medical students on their two-month internal medicine clerkship have been required to keep a professionalism journal. Accessing a password-protected Web site, they are asked to record narratives of two rotation experiences, in which they were present as participants or observers, that manifested professionalism(or lack thereof).9,19 After writing the narrative in a free-text area, they also check off any of the eight professionalism categories that they consider relevant to their experience. 

At the end of the clerkship, the clerkship director—the only person who has access to these narratives—collates and duplicates them for use in a small-group discussion. Group members first read through all of the narratives and then are asked to identify and read aloud one or more that caught their attention. A faculty-facilitated discussion of professionalism issues embedded in the selected narratives then ensues. Once the discussion is completed, the narratives are warehoused until the students graduate (to assure students that they are protected from any risk of reprisal).

분석 

Analysis

We used several statistical analyses to explore the relationships between the students’ experiences (domains and themes) that emerged in our earlier thematic analysis9 and the professionalism categories checked off by the student–authors.

결과

Results

학생 경험의 개괄

Brief overview of student experiences

학생들의 경험 분석은 프로페셔널리즘에 관한 문헌에서 보여지는 기존의 범주 언어가 아닌 자유 텍스트 서술과 학생의 "살아있는"경험의 자연어에 뿌리를두고 있습니다. 그럼에도 불구하고 학생들의 경험을 묘사하는 주제 중 일부는 존경, 보살핌, 책임감과 같은 전문직업성과 관련된 잘 알려진 가치와 행동 용어를 사용하였다. 한편, 어떤 학생의 서술은 문헌에서 특별히 인용되지 않은 행동들을 포함했다.

The analysis of students’ experiences was rooted in the free-text narratives and the natural language of student “lived” experience, not in any predefined categorical language drawn from specific literature about professionalism. Some of the themes describing student experiences, nevertheless, used well- known values and behavioral terminology related to professionalism, such as respect, caring, and responsibility, whereas other student narratives included behaviors not specifically cited elsewhere in the professionalism literature, such as 

• capitalizing on teaching opportunities, 

• creating an (un)welcoming environment, and 

• spending time taking care of patients, patients’ education and understanding.

학생 경험의 카테고리 분포

Distribution of students’ experiences within and across professionalism categories

75%이상의 행동이 하나 이상의 카테고리에 해당됨. 

Table 1 shows the associations students made between their experiences and the categories of professionalism. More than three-fourths (77%) indicated that more than one category was relevant to their narrative. Students checked off a mean of 2.9 categories for each narrative (SD  1.8, range 0–8), suggesting that the narratives are rich with heuristic value.

학생 경험에서 전문직업성 카테고리 예측

Prediction of professionalism categories from students’ experiences

Table 2 displays associations between varieties of students’ experiences and professionalism categories that are specific to the pair, as demonstrated by logistic regression models.

전문직업성 카테고리와 가장 많이 유의하게 연관된 학생 경험은 의사소통과 팀으로 일하는 것 이었다

The student experience that has a significant relationship with more professionalism categories5 than any other (including altruism, honor and integrity, excellence and scholarship, knowledge and skills, and leadership)is communicating and working in teams (for illustrative quotes, see Table 3).

학생이 토론을 위해 선택한 네러티브에 존재하는 경험과 전문직업성 카테고리

Experiences and professionalism categories present in narratives students selected for discussion

During the six-month study period, 12 small-group discussions were facilitated by two of the authors (T.S.I. and R.M.F.). During that period, 27 out of the 272 narratives were selected by the students for discussion in these groups. Table 4 displays the distribution of student experience and professionalism categories checked off within this subset of narratives.

고찰

Discussion

우리는이 연구 결과가 성찰적 내러티브를 전문직업성을 가르치는 도구로 사용하기로 선택한 의대의 교수진에게 고무 될 것으로 기대합니다. 학생 내러티브에 설명 된 경험은 다양하며 기존의 모든 전문성 범주를 다룹니다. 우리의 데이터에 따르면 학생들은 숨겨진 / 비공식 커리큘럼에서 자신의 경험을 직접적으로 그리고 다양한 차원의 전문성에 연결합니다.

We hope the findings of this study will be encouraging to faculty in medical schools who have chosen to use reflective narratives as a tool to teach professionalism. The experiences described in the student narratives are diverse and touch on all of the conventional categories of professionalism. our data suggest that students do connect their experiences in the hidden and informal curriculum directly and immediately to various dimensions of professionalism.

이 연구 결과는 또한 학생 관점에서 전문직업성을 구체화 할 수있는 구체적인 행동에 대한 이해와 학생이 전문직업성에 대해 적극적으로 학습하고있는 상황에 대한 이해를 심화시켰다. 그 행동에는 의학 - 임상 상호 작용과 교육 및 학습 환경에서의 경험이 포함되었습니다. 로지스틱 회귀 분석 결과에 따르면 학생들은 임상 환경 (예 : 환자, 가족 및 동료와의 관계)에서 실행enact되어야하는 행동과 자신과 교수 간의 관계에서 중요한 것으로 여겨지는 행동을 구분한다.

The findings in this study also deepened our understanding of the specific behaviors that may embody professionalism from a student perspective25,26 and of the circumstances in which students are actively learning about professionalism. The behaviors included medical–clinical interactions and the experiences in the teaching and learning environment. The logistic regression analysis results suggest that students differentiate between behaviors that are supposed to be enacted in the clinical setting (i.e., with patients, family members, and colleagues) and those that are seen as important in relationships between themselves and faculty.

이타주의, 책임, 명예와 성실성, 존중을 나타내는 행동은 의학-임상 상호 작용 영역에 자리 잡고 있지만 탁월함, 리더십, 지식과 기술은 교육 및 학습 환경에서 관찰되는 것이다. 조사 결과는 배려와 연민, 의사 소통이 구체적으로 교육 및 학습 영역에서 점검 항목 중에서 부정적으로(덜 자주) 관련되었으며, 이는 학생들은 [선생님이 학생들에게compassionate를 갖는 것을 기대하지 않는다는 것]을 보여줍니다.

Behaviors manifesting altruism, responsibility, honor and integrity, and respect are situated in the medical–clinical interaction domain, whereas excellence, leadership, and knowledge and skills are observable in the teaching and learning environment. The findings show that caring, compassion, and communication specifically was negatively (less frequently) associated with checked items in the teaching and learning domain, suggesting that students are not expecting their teachers to be compassionate toward them as students.

Ginsburg와 동료들은 전문직업적 가치의 상충을 경험한 학습자는, 종종 그러한 갈등이 만들어내는 "이중 구속"에서 벗어나기위한 전략으로 "해체step out of"를 사용한다고 주장한다. 분리적dissociative 대처 전략이 전문직업적 정체성 형성에 미칠 수있는 부정적인 영향은 더 큰 관심을 가질 만하다.

Ginsburg and colleagues28 argue that learners facing a conflict of professional values often use “dissociation” as a strategy to “step out of” the “double-bind” that such a conflict creates for them. The potential negative impact of dissociative coping strategies on professional identity formation deserves further attention.

팀 내에서 의사 소통하고 일하는 것(communicating and working within teams)은 5 개의 전문성 범주 (의학 - 임상 상호 작용 및 교육 및 학습 환경 영역 모두)의 핵심 동력 인 것으로 보입니다. 비록 이 주제에서 서술은 상대적으로 적었지만, 이러한 경험은 다양한 전문성 범주의 생각을 이끌어내는 강력한 것들이었으며, 아마도 환자 간호와 학생 학습 모두를 위한 팀웍의 특별한 중요성을 나타낼 수 있었다.

One experience, communicating and working within teams, seems to be a key driver for five professionalism categories (in both the medical–clinical interactions and teaching and learning environment domains). Even though relatively few narratives were identified within this theme, these experiences were powerful ones that elicited thoughts of various professionalism categories, possibly indicating the special importance of teamwork for both patient care and student learning.

그러나 팀워크 그 자체가 전문성의 속성으로 명시 적으로 고려되지 않는다는 것은 흥미 롭다. 학생의 네러티브를 비롯해서 퀄리티 및 환자 안전에 관한 문헌이 급증함에 따라 전문성의 속성으로서 팀과 팀워크의 중요성을 다시 생각하게된다.

Yet it is interesting that teamwork in itself is not explicitly considered an attribute of professionalism.21 Student narratives, as well as a burgeoning literature in quality and patient safety, may give us pause to reconsider the importance of teams and teamwork as an attribute of professionalism.

다양한 전문성 범주와 긍정적 내러티브 사이의 중요한 관계, 그리고 긍정적 내러티브가 대부분이었다는 사실은 reassuring하며, 네러티브와 성찰의 사용 또는 잠재 교육과정의 일반적 측면에서 전문직업성의 lapse가 파다하다는 것에 대한 우려를 덜어준다. 학생들은 긍정적 (부정적인) 역할 모델을 통해 다양한 형태의 전문직업성에 대해 알아보고 감사하고 배우며 전문가로서 우리에게 긍정적으로 반영되는 행동을 인정하고 감사하게 생각합니다. 특히 긍정적 인 내러티브는 우수성과 지식 및 기술에 대해 배우는 것과 관련이있는 것으로 보입니다.

The significant relationship between various professionalism categories and positive narratives, and the fact that the positive narratives were in the majority, is reassuring and may alleviate general concerns about overweighting lapses of professionalism27 in the use of narrative and reflection and in the hidden curriculum in general. It seems that students notice, appreciate, and learn about various forms of professionalism from positive (as well as negative) role models, and acknowledge and appreciate actions that reflect positively on us as professionals. In particular, positive narratives seem to be associated with learning about excellence and knowledge and skills.

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Acad Med. 2011 Mar;86(3):369-77. doi: 10.1097/ACM.0b013e3182087d15.

Which experiences in the hidden curriculum teach students about professionalism?

Karnieli-Miller O1, Vu TR, Frankel RM, Holtman MC, Clyman SG, Hui SL, Inui TS.

Author information

1

Department of Community Mental Health and Center for Excellence in Patient-Professional Relationships in Health Care, University of Haifa, Haifa, Israel. OritKM@gmail.com

Abstract

PURPOSE:

To examine the relationship between learner experience in the "hidden curriculum" and student attribution of such experiences to professionalism categories.

METHOD:

Using the output of a thematic analysis of 272 consecutive narratives recorded by 135 students on a medical clerkship from June through November 2007, the authors describe the frequency of these experiences within and across student-designated Association of American Medical Colleges-National Board of Medical Examiners professionalism categories and employ logistic regression to link varieties of experience to specific professionalism categories.

RESULTS:

Thematic analysis uncovered two main domains of student experience: medical-clinical interaction and teaching-and-learning experiences. From a student perspective the critical incident stories evoked all professionalism categories. Most frequently checked off categories were caring/compassion/communication (77%) and respect (69%). Logistic regression suggested that student experiences within the teaching-and-learning environment were associated with professionalism categories of excellence, leadership, and knowledge and skills, whereas those involving medical-clinical interactions were associated with respect, responsibility and accountability, altruism, and honor and integrity. Experiences of communicating and working within teams had the broadest association with learning about professionalism.

CONCLUSIONS:

Student narratives touched on all major professionalism categories as well as illuminating the contexts in which critical experiences emerged. Linked qualitative and quantitative analysis identified those experiences that were associated with learning about particular aspects of professionalism. Experiences of teamwork were especially relevant to student learning about professionalism in action.

PMID:

 

21248599

 

DOI:

 

10.1097/ACM.0b013e3182087d15