'이게 일반적인가요?' 전임상 학생의 프로페셔널 딜레마에 대한 접근(Med Educ, 2011)

'이게 일반적인가요?' 전임상 학생의 프로페셔널 딜레마에 대한 접근(Med Educ, 2011)

‘Is that normal?’ Pre-clerkship students’ approaches to professional dilemmas

Shiphra Ginsburg1 & Lorelei Lingard

도입

INTRODUCTION

프로페셔널리즘은 어떤 맥락에서의 일련의 행동으로 정의 될 수 있습니다 .1) 따라서 프로페셔널리즘에 대한 연구에서 맥락이 반복적으로 주요 변수로 부각되는 것은 전혀 놀랍지 않다. 연구자들은 프로페셔널 또는 unprofessional 이라고 학생들이 보는 것은 훈련 단계에 따라 다르다는 것을보고했다 .3 학생들은 단계에 따라 프로페셔널리즘의 서로 다른 측면을 강조하며, 윤리적 민감성은 종종 학년이 올라가며 감소한다 .5,6

Professionalism can be defined as a set of behaviours in context.1,2 Not surprisingly then, context repeatedly emerges as a key variable in studies of medical student professionalism. Researchers have reported that what students view as professional or unprofessional varies by stage of training,3 that students at different stages emphasise different aspects of professionalism4 and that ethical sensitivity often declines during medical school.5,6

프로페셔널리즘 개발이 임상실습에서 시작되는 현상이 아니기 때문에 전임상실습과 임상실습 학생 간의 차이점이 중요합니다. 오히려 학생들은 의과대학 초기 경험에서 의사로서 프로페셔널리즘을 형성하기 시작합니다. 이런 현상은 'proto-professionalism'이라고 불립니다.

differences between pre-clerkship and clerkship students are important because it has been recognised that professional development is not a phenomenon that commences in clerkship; rather, students begin to form their professional ethos as medical practitioners from their early medical school experiences, a phenomenon that some have termed ‘proto-professionalism’.7

대부분의 북미 의과대학에서 Pre-clerkship 커리큘럼은 임상 환경에 대한 조기 노출을 포함합니다. 이 때에는 직접적인 환자 치료에 대한 책임이 없지만, 이러한 노출을 통해 임상 및 교육 환경에서 직접 관찰하고 참여합니다. 이러한 경험은 학생들의 긍정적이든 부정적이든 전문직 정체성 개발에 강력한 영향을 줄 수 있습니다. 한 연구에서 의과 대학에 막 입학한 학생들도 전혀 임상 encounter가 없었음에도 휴머니즘과 전문직업적 책무에 대해서 상당한 이해를 갖추고 있었다. 물론 비록 이들은 실제로 이러한 속성들이 어떻게 작용 하는지를 알지는 못했다.

most Pre-clerkship medical curricula in most North American incorporate early exposure to clinical environments. They are not responsible for direct patient care, but through these exposures they observe and participate directlyin the clinical and educational environments. These experiences can have powerful effects on students’ development of professional identities, in both positive and negative ways.3,8,9Matriculating medical students in one study were shown to have a good understanding of humanism and professional responsibilities, even prior to any clinical encounter,although they did not necessarily know how these attributes would function in practice.10 

프로페셔널리즘 연구에서 중요한 부분은 학생들이 전문적으로 어려운 상황에서 의사 결정을 내리는 방식을 탐구하는 것입니다.

An important thread in professionalism research concerns the exploration of how students make decisions in professionally challenging situations.

그러나 각 학생이 직접 또는 개인적으로 마주 쳤던 딜레마에 대해 글을 썼거나 토론했기 때문에 프로페셔널리즘 영역과 반응의 다양성으로 인해, 학생들 간의 직접적인 비교를 할 수 없었다. 또한, 학생들의 행동에 대한 묘사와 그 뒤에 가려진 rationale는 시간의 흐름과 반성 과정 자체에 의해 영향을 받을 수 있습니다. 마지막으로, 학생들이 자신의 훈련에 대해 성찰하고 토론하거나 토론 할 특정 사건을 선택하는 시간이 주어졌기 때문에 좋은 인상을 줄 만한 사건을 선택할 수도 있었다. 이러한 유형의 impression management는 실제로뿐만 아니라 연구 연구에서도 나타납니다.

However, because each student reported in these studies wrote about or discussed a dilemma he or she had personally encountered, the diversity of professionalism domains and responses precluded a direct comparison between students.11–13 Further, students’ descriptions of their actions and the rationales behind them may have been affected by the passage of time and the process of reflection itself; Finally, as the students were given time to reflect upon their training and to select particular incidents to write about or discuss, they may have been more likely to choose those they felt showed them in a good light.11–13 This type of impression management has been shown to occur in research studies, as well as in practice.

이러한 효과를 줄이기 위해 다른 연구에서는 학생들이 현장에서보고 반응해야하는 표준화 된 딜레마를 활용하여 더 많은 원시 반응과 반응을 유발하고 학생들 간의 비교를 허용했습니다.

To mitigate these effects, other studies have utilised standardised dilemmas that students must view and respond to on the spot, provoking more raw reactions and responses and allowing for comparison between students.

전문직 딜레마를 발견하고, 대안을 검토하고, 행동 방법을 결정할 때 임상실습 학생에게 영향을주는 요소들은 다음이 있다.14-16

factors that influenced clerkship students as they identified a professional dilemma, weighed alternatives, and decided how to act.14–16

• 전문성의 원칙 (인정하든 인정하지 않든)

• 감정 (감정, 신념, 직감)

• 행동의 함의에 대한 고려 (환자, 다른 사람들 또는 그들 자신에게) .17

principles of professionalism (which could be considered as avowed or unavowed), issues of affect (feelings, beliefs, gut instincts) and consideration of the implications of their actions (on patients, others or themselves).17

방법

METHODS

This was a constructivist grounded theory19 study in which the current project was informed by our previous conceptual work in the domain. 

• A constructivist approach acknowledges that researchers’ background assumptions, disciplinary perspectives and programmatic efforts along a line of study shape their research processes and conceptual emphases.19 

• In this tradition, this study used as ‘sensitising concepts’ recurrent themes from our past research into professionalism as a starting point from which to challenge, elaborate and refine existing theoretical concepts around student professionalism.11,17,18

모집

Methodologically, the study involved structured interviews prompted by five standardised scenarios depicting medical students in professionally challenging situations. Potential participants were all medical students in Years 1 and 2 at the University of Toronto in 2004. 

Following research ethics board approval, recruitment was conducted via e-mail to class listserves. 

• Participant responses were sent directly to the research assistant, who was unknown to participants, so that the principal investigators did not know who did or did not participate. 

• This process was engaged to protect participants’ anonymity and to avoid any impression of coercion because the lead researcher (SG) was involved in the administration of the undergraduate curriculum at the time. 

• Sample size was estimated to be sufficient based on the principle of theoretical saturation20 and our previous experience with this methodology (i.e. with a relatively homogeneous population, we expected to reach saturation with approximately 15 interviews per group). 

• There were no exclusion criteria and we accepted the first 15 students from each class who volunteered.

비디오

The five videos were created based on previous research (Fig. 1).11,17 Briefly, the scenarios were developed based on focus group discussions in which clinical clerks at three medical schools discussed lapses in professionalism of which they had personal knowledge. 

• The cases ultimately chosen were meant to be challenging, to feature no obvious right answer and to cover a range of professionalism domains. 

• Each scenario was made into a 1.5–2.0-minute video which ended at the point at which the student depicted in it must act (i.e. must either say or do something as an immediate response to events in the scenario). 

• Each participant took part in a private, structured interview conducted by the same research assistant, during which the five videos were played in the same pre-set order. 

• This order was maintained to minimise any potential effects of confounding that might result from cueing between one scenario and the next. 

Following each video, students were asked 

• what they would do next, 

• why they would do it, and 

• what might happen as a result of that action. 

Interviews were audiotaped and transcribed verbatim.

The transcript for each interview was analysed with attention to both sensitising concepts from previous analytical structures and novel, emergent themes. 

• Thus, we coded instances that were reflective of the theoretical framework developed in our previous research (Principles [avowed or unavowed], Affect and Implications).17,18,39 

• We also undertook an open coding process to capture themes that were either new or not adequately explained by the previous framework.21 

• Codes were modified in an iterative process using constant comparison by the authors and the research assistant. 

• We resolved disagreements by returning to problematic instances in the data and coming to consensus. 

• The sample of 30 interviews offered recurrent and elaborated instances of both existing and new themes, and was therefore considered adequate for saturation. NVivo Version 8.0 (QSR International Pty Ltd, Doncaster, Australia) was used to facilitate coding and analysis. 

• Although the use of numbers in qualitative research can be considered controversial, it has become more accepted (and at times has even been advocated).22 

• We included simple counts of the presence of codes to illustrate their relative prevalences.

결과

RESULTS

임상실습과 preclerkship 데이터 세트 사이의 주제와 진화에 대한 간략한 설명과 설명 인용을 표 1과 2에서 볼 수있다.

A brief description of themes and their evolution between the clerkship and preclerkship datasets, along with illustrative quotations, can be seen in Tables 1 and 2.

임상 경험이 부족 함에도 불구하고, 이 전임상 학생들은 각 경우에 관한 토론에 광범위하게 참여하고, 행동에 대한 많은 제안을 제공하며,이 행동의 배후에 많은 이유를 설명했습니다.

despite their lack of clinical experience, these junior students engaged extensively in discussion around each case, offered many suggestions for action and explained many rationales behind this action.

원칙과 불가피성

Principles and imperatives

시나리오를 통해 추론 할 때, 전임상 학생들은 임상 학생들과 동일한 전문성 원칙을 언급했다 (표 1).

When reasoning through the scenarios, pre-clerkship students referenced the same general principles of professionalism as clinical clerks had done (Table 1).

두 가지 반복되는 패턴이 전임상 학생을 임상 학생과 구별합니다 : 

• '시스템을 안다'는 주제와 

• 환자의 '권리'에 초점을 두는 것

Two recurrent patterns distinguished preclerkship students from their clerkship counterparts: the prominence of the theme ‘know the system’, and the focus on patients’ ‘rights’.

임상실습생의 자료에서 '시스템을 아는 것'의 중요성은 비교적 사소한 주제의 패턴을 나타냈다. 그러나 전임상 학생들은이 아이디어를 중요하게 보았다. 이에 대한 한 가지 가능한 이유는 전임상 학생들이 병동에 대한 경험이 적기 때문에 '어떻게 일하는가'에 대해 더 염려하기 때문일 것이다

In the clerkship data, the importance of ‘knowing the system’ represented a relatively minor thematic pattern. However, the current students referenced this idea pervasively . One possible reason for this is that junior students have less experience on the wards and so are more anxious and concerned about ‘how things work’. 

두 번째 큰 차이점은 전임상 학생들이 환자와의 동일시를 반영하는 방식으로 몇 가지 원리를 골라내는 것이 었습니다. 이러한 동일시identification이 임상실습 학생에도 있었지만, 전임상 학생에게서 환자의 관점이 보다 강하게 자리잡았다. 환자의 '권리'를 표현하는 방법은 '그들의 선택이다'(여러 경우), '그것은 자신(환자)의 몸'(여러 사례), '모든 환자는 치료를 거부할 권리가 있고 요청할 권리가 있다 (모든 경우)'와 같은 문구를 사용하였다.

The second major difference involved the current students’ framing of some principles in a way that reflected their identification with patients. Although this identification was present in the clerkship data, pre-clerkship responses were more strongly positioned from a patient’s perspective. One way in which this manifested was in students’ invocation of patients’ ‘rights’, as illustrated by the use of phrases such as ‘It’s their choice’ (multiple instances), ‘It’s their body’ (multiple instances) and ‘Every patient has the right to refuse treatment, or object or make a request’ (Scenario 5, Student 10, Year 2).

감정

Affect

임상 실습생에 대한 연구에서, 주제별 영향력 범주는 전문적인 딜레마에 직면하는 법을 결정할 때 자신의 내적 감정, 직감 또는 신념에 의존하는 경향을 반영했다 .17) 전임상 학생에서도 Affect가 있었지만, 덜 눈에 띄는 패턴을 보여 주었고, 1 학년과 2 학년의 학생 사이에 눈에 띄는 차이가있었습니다.

In the original study of clinical clerks, the thematic category of Affect reflected student reports of relying on their internal feelings, gut instincts or beliefs when deciding how to act in the face of professional dilemmas (Table 2).17 In the current dataset, students also referenced Affect, but their references demonstrated a less prominent pattern and there was a notable difference between students in Years 1 and 2.

함의

Implications

우리는 현재 학생들에게서 얻은 데이터와 이전의 임상실습 학생의 데이터에서, 어떻게 행동할지를 결정할 때 학생이 '행동의 함의'를 고려하는 것에 대해 차이점을 발견하지 못했습니다 .17

We found no recurrent differences between the data derived from the current students and our previous clerkship data regarding students’ consideration of the implications of their actions when deciding how to act.17

고찰

DISCUSSION

1, 2 학년 학생들의 프로페셔널 딜레마에 대한 접근 방식은 이전의 제한된 임상 경험에도 불구하고 임상실습학생의 접근 방식과 매우 유사했습니다. 임상실습학생처럼, 이 학생들은 행동 방법을 결정할 때 전문성의 원칙과 감정의 문제를 언급하고 그들의 행동의 함의를 고려했습니다. 그러나 전임상학생들은 본능과 감정에 대한 의존도가 낮았으며 시스템 관련 문제에 더 관심이있었습니다.

The approaches of students in Years 1 and 2 to professional dilemmas were very similar to those of clinical clerks, despite the former’s limited clinical experience. Like clerks, these students, in deciding how to act, made reference to principles of professionalism and issues of affect, and considered the implications of their actions. However, pre-clerkship students expressed less reliance on instincts and emotions, and were more concerned with systems-related issues.

전임상 단계에서의 학생들의 초점은 주로 의학 지식과 임상 기술 습득에 있지만, 학생들이나 감독자가 명시적으로 다루지 않을 수도있는 직업적 정체성을 형성합니다. 이 연구의 결과는 학생들의 전문직 정체성 형성의 맥락에서 가장 잘 이해 될 수 있습니다.

Students’ focus in the pre-clerkship stage is mostly on acquiring medical knowledge and clinical skills, but they are also forming professional identities, a process that may not be explicitly acknowledged by students or their supervisors. Our findings may be best understood in the context of students’ professional identity formation.

감정: 이것에 대한 한 가지 가능한 이유는 이 단계의 학생들도 의사 역할을 수행하기를 열망 할 수 있기 때문입니다. Monrouxe에서 제안한 것처럼 "의사처럼 이야기하는 법은 내용을 배우는 것만큼이나 중요합니다."23

One possible reason for this is that students at this stage of training may be eager to take on the doctor role, which, as suggested by Monrouxe, may be ‘as much about learning to talk like a doctor as it is about learning the content’.23

하스 (Haas)와 샤피 어 (Shaffir)는 학생들이 흔히 "역량의 망토"뒤에 감정을 숨긴다고 지적했으며, 다른 연구자들도 의과 대학에서 학생들의 감정 억제에 대해 기술했다 .25,26이 문헌을 고려할 때, 우리의 연구 결과는 전임상 학생들이 [임상 상황에서 자신의 '개인적인'감정이나 본능을 고려하거나 명료하게 표현하는 것]이 부적절하다고 느끼는 감정을 보여주는 것일 수 있다.

Haas and Shaffir noted that students often hide their feelings behind a ‘cloak of competence’, and others have also described the suppression of emotions in medical school.25,26 In view of this literature, our results may reflect a sense on the part of pre-clerkship students that it would be inappropriate to consider or articulate their own ‘personal’ feelings or instincts in the clinical situations presented to them.

이와 관련하여, 전임상 학생들은 지식과 내용에 더 초점을 맞추기 때문에, 병원 환경에서 외부인처럼 느껴질 수 있습니다. 아마도 이 결과로 학생들은 선생님 앞에서 '인상 관리impression management'에 관심을 보이는 것으로 나타났습니다. 이것은 사회적으로 바람직한 반응의 한 요소이며, 심지어 연구 환경에서도 나타나기도 한다. 따라서 본 연구의 학생들은 면접관이나 연구 조사관에게 전달되는 인상을 관리하기 위하여 affect를 professional decision에 주요 rationale로 표현하지 않았을 수 있다.

Related to this is the notion that pre-clerkship students may be more focused on knowledge and content, which can make them feel like outsiders in the hospital environment.27 Perhaps as a result of this, students have been shown to be concerned with ‘impression management’ in front of their teachers; this is one component of socially desirable responding and has been shown to occur even in research settings.28 Thus, students in our study may have avoided expressions of Affect as a rationale for professional decisions as a way of managing the impressions they were conveying to the interviewer or to the study investigators.

학생들이 자신의 추론에서 '시스템을 아는 것'을 되풀이하며, 훈련의 초기 단계에 있음을 반영합니다. 그들은 시스템을 알지 못하며, 그것이 어떻게 작동하는지 불확실해했다. 이들은 '규칙'및 '계층 구조'와 같은 용어를 사용하면서 그들이 '무엇을 해야 하는지'를 궁금해했다. 더 나아가, 학생들은 빈번하게 '시스템이 존재한다'는 것에 대한 믿음을 보여주었으며, 따라서 일단 그 시스템을 이해하기만 하면 문제를 해결하는데 도움이 될 것이라고 생각했다.

Students’ recurrent reference to ‘knowing the system’in their reasoning also reflects their early stage of training. They frequently spoke about not knowing the system and being uncertain about how things worked, using terms such as ‘rules’ and ‘hierarchy’ and wondering what they were ‘supposed to do’. Further, they frequently exhibited a sense of trust that a system existed, which, once understood, wouldhelp them resolve problems: 

'... 의대생, 심지어는 거주자, 심지어는 주니어 스태프 멤버 일지라도, 당신은 항상 당신이 무엇을 해야할지를 듣게 될 것입니다.'(시나리오 5, 학생 2, 2 학년)

‘…as a medical student, and even as a resident, and even as a junior staff member, you’re always going to have someone telling you what to do.’ (Scenario 5, Student 2, Year 2)

학생들은 시스템을 배우고 이해하기를 열망하는 것처럼 보였지만, 어딘가 잠금을 해제 할 수있는 비밀 코드가 있거나 누군가가 무엇을 해야할지 항상 알려줄 것이라는 나이브한 기대를 드러냈다. 이러한 결과는 또한 초기 의대생이 모호성이나 불확실성에 대한 상대적으로 낮은 수준의 내성을 제공한다는 것을 시사한다 .29-31

Students seemed eager to learn and understand the system, but revealed a naı¨ve hope that there might be some secret code to unlock or that someone would always be around to tell them what to do. These findings also suggest junior medical students’ relatively low levels of tolerance for ambiguity or uncertainty.29–31

모든 연구자는 아니지만 일부 연구자들은 모호성에 대한 내성이 낮으면 퍼포먼스가 저하 될 수 있다고 제안했습니다. 이러한 반응은 Kohblerg의 도덕 발달 단계에 근거한 종단 적 연구에서 설명한 바와 같이, 저학년 의대학생들과 관련된 도덕적 발전의 '통상적 인'단계를 반영 할 수 있습니다. 이 단계는 다음과 같은 특징이 있습니다.

• 기대에 순응하기

• 다른 사람들의 승인을 얻기

• 권위를 존중

• 질서 유지

그러나 이것은 직업적 정체성의 발달이 반드시 특정 단계를 따르는 것으로 고정되어있음을 의미하지는 않으며, 훈련 과정을 거치며 자연스럽게 펼쳐지는 매끄러운 흐름을 따름을 의미하지도 않는다. 오히려, 이러한 단계는 아마도 유동적이고 상황에 따라 다르며, 학생의 상황의 특성과 이전의 경험에 따라 서로 다른 수준에서 수준에서 작동한다. 그럼에도 불구하고, 지금껏 우리는 전문성에서 중요한 맥락적 요소로서 단계stage를 무시함으로써, 교육을 위한 중요한 기회를 놓쳐왔다.

Some, but not all, researchers have suggested that less tolerance for ambiguity might translate into poorer performance.23,30,33 Such responses may be reflective of the ‘conventional’ stage of moral development associated with junior medical students, as described in a longitudinal study based on Kohblerg’s stages of moral development.34 This stage is characterised by conformation to expectations, gaining the approval of others, respecting authority and maintaining order. however, this is not meant to imply that the development of professional identity necessarily follows a lock-step movement through specific stages, or that it follows a smooth arc that naturally unfolds during training. Rather, these phases are probably more fluid and context-dependent, with students functioning at different levels depending on the specifics of the situation and their own previous experience.37,38 Nonetheless, by neglecting stage as an important contextual factor in professionalism, we miss important opportunities for education.

우리의 발견은 교육자들이 학생들의 의대 초반부터 전문성 개발에 더 많은 관심을 기울일 것을 요구합니다. 트레이닝 초기 단계에서도 의대생들은 전문적인 딜레마에 직면 해 있습니다. 교수개발에 대한 노력은 

• 전임상 학생과 임상실습 학생 사이의 정체성 차이, 

• 전문적 딜레마에 대한 그들의 반응, 

• 딜레마가 발생할 때 적절한 접근법을 가르치는 전략

..에 중점을 두어야한다.

Our findings reinforce calls for educators to pay more attention to students’ professional development, starting at the beginning of medical school. Even at the earliest stages of training, medical students are faced with professional dilemmas that they must negotiate, with little experience to guide them. Efforts at faculty development should focus on 

• increasing awareness of the difference between pre-clerkship and clerkship students’ emerging identities, 

• their responses to professionalism dilemmas, and 

• strategies for teaching appropriate approaches for use when dilemmas do occur.

novice 학생들은 그들이 전문직 정체성을 구축하는 과정에서 의사의 역할을 감당할 필요성을 느끼면서, 학생의 역할을 숨기고 감정을 억제한다. 그러나 일부 연구에 따르면 교수들은 학생들의 감정과 본능을 일반적인 수준보다 더 인정해주고 용서할 수 있음을 보여주었고, 학생의 감정과 본능이 그들의 발전을 돕는데 보다 명확하게 사용될 수 있습니다. 학생들의 교육 수준에 따라 지식 및 임상 기술에 대한 교육 및 평가를 조정하는 것처럼, 우리는 프로페셔널리즘 교육에 대해서도 발달 단계를 명시적으로 인정하고 접근해야합니다.

As novice students construct their professional identities, they seem to feel a need to take on the role of doctor and shed the role of student, which involves the suppressing of emotions; however, some research has suggested that faculty doctors may be more accepting and forgiving of students’ emotions and instincts than is usually acknowledged, and this information could be used more explicitly to aid in students’ development.15,39 Just as we tailor our teaching and evaluation of knowledge and clinical skills to students’ level of training, we should approach their professionalism education by explicitly acknowledging their stage of development.

---

Med Educ. 2011 Apr;45(4):362-71. doi: 10.1111/j.1365-2923.2010.03903.x.

'Is that normal?' Pre-clerkship students' approaches to professional dilemmas.

Ginsburg S1, Lingard L.

Author information

1

Department of Medicine, University of Toronto, Toronto, Ontario, Canada. shiphra.ginsburg@utoronto.ca

Abstract

OBJECTIVES:

Context has been recognised as a key variable in studies of medical student professionalism, yet the effect of students' stage of training has not been well explored, despite growing recognition that medical students begin to form their professional ethos from their earliest medical school experiences. The purpose of this study, which builds on previous research involving clinical clerks, was to explore the decision-making processes of pre-clerkship medical students in the face of standardised professional dilemmas.

METHODS:

Structured interviews were conducted with 30 pre-clerkship (Years 1 and 2) medical students at one institution. During the interviews, students were asked to respond to five videotaped scenarios, each of which depicted a student facing a professional dilemma. Transcripts were analysed using an existing theoretical framework based on a constructivist grounded theory approach.

RESULTS:

Pre-clerkship students' approaches to professional dilemmas were largely similar to those of clerks, despite their limited clinical experience, with several notable exceptions. For example, reliance on instincts and emotions was not as pervasive, but concerns with systems-associated issues were more recurrent. These findings were explored in the context of theory on professional identity formation.

CONCLUSIONS:

As the novice student constructs a professional identity, he or she may feel the need to take on the role of doctor and shed that of student, a process that involves the suppressing of emotions, but this may be misguided. Educators should be aware of these stages of identity formation and tailor their teaching and evaluation of professionalism accordingly.

© Blackwell Publishing Ltd 2011.

PMID:

 

21401684

 

DOI:

 

10.1111/j.1365-2923.2010.03903.x

[Indexed for MEDLINE]