만능 열쇠? 프로페셔널리즘 프레임워크 만들기(Acad Med, 2011)

만능 열쇠? 프로페셔널리즘 프레임워크 만들기(Acad Med, 2011)

Does One Size Fit All? Building a Framework for Medical Professionalism

Ming-Jung Ho, MD, DPhil, Kun-Hsing Yu, MD, David Hirsh, MD, Tien-Shang Huang, MD, and Pan-Chyr Yang, MD, Ph

의료 프로페셔널리즘은 지난 10 년간 세계적 관심을 얻었습니다 .1-4 전 세계 90 개 전문기구가 의사 헌장을 승인했으며, 이들은 전문 분야의 다양성과 전통을 인정하면서, 공통 주제에 기초한 "의료 전문성의 기본 및 보편적 원칙과 가치"를 재확인하였다.

Medical professionalism has gained global attention over the past decade.1–4 Ninety professional organizations worldwide have endorsed the Physician Charter,5 which, while acknowledging the diversity of medical practices and traditions in its preamble, reaffirms “the fundamental and universal principles and values of medical professionalism ” based on common themes

전 세계의 전문 분야와 국가에 걸쳐 여러 조직들은 헌장을 신속히 채택했습니다 .5 결과적으로 비서구 국가에서도 학부 및 대학원 의학교육에 대한 북미의 인증방식에 따라 의료 프로페셔널리즘을 채택하고 있습니다.

organizations adopted the charter quickly across specialties and countries internationally.5 As a result, non-Western countries are adopting medical professionalism according to the North American forms of accreditation standards for both undergraduate and graduate medical education.8,9

기관 및 전문 단체가 프로페셔널리즘에 대한 표준화 된 가이드라인을 채택하더라도 학자들은 프로페셔널리즘이 맥락에 따라 다르다는 것을 계속 강조하며, 사회적으로 구성됨social construct을 강조합니다.

Even as agencies and professional organizations adopt standardized guidelines for professionalism , scholars continue to emphasize that professionalism  is context dependent13 and is a social construct.3

이 틀의 보편적 적용 가능성에 관한 문헌이 부족하다 .15-17

there is a paucity of literature on the universal applicability of this framework.15–17

배경

Background

대만의 의료 전문가들은 1895 년부터 1945 년까지 50 년간 식민 통치 기간 동안 일본 최초의 의대를 설립 한 이래로 많은 존경과 자율권을 누리고 있습니다. 그 후 수십 년 간 의료 전문가는 의료 및 공공 보건 서비스를 제공했을뿐만 아니라 국가 근대화와 민주화에 적극적으로 주도적 인 역할을한다. 1995 년 국민 건강 보험이 설립됨에 따라 의료기관의 총 예산이 제한되어 의사들이 비용을 통제하고 이익을 증대 시키도록 재정적 압력을 가했다. 의사들은 미용 치료와 같은 국민건강보험에 가입하지 않은 서비스에 점점 더 관심을 갖게 되었고, 이는 의사들의 전문가 이미지 손상을 가져왔다.18,19

Medical professionals in Taiwan have enjoyed much respect and autonomy since the Japanese established the first medical school here during their 50 years of colonial rule between 1895 and 1945. In the decades that followed, medical professionals not only provided medical and public health services but also played active leadership roles in the modernization and democratization of the country. The establishment of the National Health Insurance in 1995 limited the total budget of medical institutions, which put financial pressures on physicians to control cost and to increase profit. As physicians became increasingly interested in services not covered by the National Health Insurance, such as cosmetic treatments, their professional image eroded.18,19

우리의 기관인 National Taiwan University College of Medicine (NTUCM)은 국가의 의학 프로페셔널리즘 추구를 추구하는 대학의 사례입니다.

Our institution, National Taiwan University College of Medicine (NTUCM), serves as an example of a university seeking to address its nation’s pursuit of medical professionalism .

우리는 히포크라테스적 전통이 비의료전문가에게는 익숙하지 않은 전통적인 대만 문화에서, "의료 프로페셔널리즘"의 개념이 부족하고, 초등 교육 수준에서 유교 교리가 강조되는 상황을 해결하려는 것이다.

The process we describe addresses the lack of the concept of “medical professionalism ” in traditional Taiwanese culture, where Hippocratic tradition is unfamiliar to nonmedical professionals, and Confucian doctrines are emphasized starting at the elementary education level.

방법

Method

NGT

NGT

Through literature reviews and consultations of experts, we determined NGT to be an effective and efficient method to elicit group values and derive consensus.24–27 

• NGT is a structured procedure for gathering insight from groups of people. 

• In the NGT process, all group members have equal opportunity to present their views, all views have equal weight, and the process for everyone to list all their ideas for discussion avoids problems associated with traditional group meetings, such as dominating personalities or obedience to authority.24–26 

• The method is used in management, clinical guidelines creation, and course evaluation in medical education.27

NGT participants.

In our NGT process, we based the selection of participants on the purposive sampling28 method. 

• We asked the chairs of various departments (including internal medicine, surgery, obstetrics–gynecology, pediatrics, nursing, and social work) at the National Taiwan University Hospital to recommend those health care workers (including chief residents, attending physicians, intensive care unit nurses, operating room nurses, ward nurses, social workers, public health workers, and hospital volunteers) whom the chairmen believed possessed differing views within each department. 

• We also asked the most active nongovernment patient support organization, the Taiwan Healthcare Reform Foundation, to suggest participants from a variety of patient support groups. 

• Most of the potential participants joined the study or recommended other suitable participants.

NGT procedure.

We oriented each group to the purpose of the meeting and the procedure that would be followed. 

• The first step was for each participant to write down what he or she considered to be the essential abilities of a professional doctor.The purpose of this exercise was to capture participants’ expectations regarding medical professionals. 

• In the second step, participants took turns naming one item from their list at a time without further discussion. This process continued until all participants had expressed all of their ideas. 

• In step three, the participants discussed all items and combined any closely related ideas into a single item. When determinations were not unanimous, the person who initially raised the item could decide whether or not to combine the idea or leave it as a separate item. 

• In the fourth step, each participant selected five items he or she regarded as most important and voted on these five items using a five-point Likert-type scale, where 5  most important and 1  least important. 

• The fifth step was to sumthe voting results and rank the items.

전문가 위원회

Expert committee

After the NGT meetings, the dean of our medical college convened an expert committee to discuss the results of all NGT meetings.

NGT 녹취록 분석

Text analysis of NGT transcript

We recorded and transcribed NGT meetings verbatim. The transcript was 123 pages, containing 113,547 Chinese characters. After the expert committee constructed the framework, we used NVivo 8.0 software (QSR International Pty Ltd.; Doncaster, Victoria, Australia) to conduct a text analysis of the transcripts of the 12 NGT sessions. The purpose of this analysis was to ensure that the expert committee represented the opinions about professionalism  attributes nominated by the participants in the consensus framework.

결과

Results

NGT 투표 결과

The NGT process voting results

Voting results of the top five items of each group are shown in Supplemental Digital Table 1, 

http://links.lww.com/ACADMED/A57.

전문가 위원회에 의한 프레임워크

The framework constructed by the expert committee

스턴은 세 가지 기본 단계 (임상 적 역량, 의사 소통 및 윤리)와 네 개의 기둥 (휴머니즘, 우수성, 책임 성 및 애타주의)이있는 그리스 성전 모양의 의료 전문성을 묘사합니다.

Stern depicts medical professionalism in the shape of a Greek temple, with three foundational steps (clinical competence, communication, and ethics) and four columns (humanism, excellence, accountability, and altruism).

반복적 인 심의를 거친 후 전문가위원회는 우리의 시각적 프레임워크가 스턴의 프레임 워크를 구성하는 기둥 꼭대기에 "integrity"을 포함해야한다는 합의에 도달했습니다. integrity은 의료 전문성의 다양한 원칙을 통합하기위한 핵심이기 때문이다.

After iterative deliberation, the expert committee reached consensus that our visual framework should include “integrity” across the tops of the columns that make up Stern’s framework because integrity is the key for integrating the different principles of medical professionalism .

녹취록 리뷰

The review of the transcript to confirm the consensus framework

참가자들의 원래 표현에 따라 회의록을 분석함으로써 NGT 참가자가 식별 한 대부분의 항목을 전문가위원회가 개발 한 NTUCM 프레임 워크에 배치 할 수있었습니다. 그림 2는 전문성을위한 NTUCM의 프레임 워크에 대한 NGT 결과의 매핑을 보여줍니다.

By analyzing the transcripts of the meetings according to the original wording of the participants, we were able to place most items identified by NGT participants within the NTUCM framework developed by the expert committee. Figure 2 shows the mapping of the NGT results on the NTUCM’s framework for professionalism .

모든 투표를 모으고 각 전문 가치의 전반적인 평점을 계산함으로써 인본주의, 의사 소통, 책임 및 윤리 (그림 3)와 같은 참가자가 가장 강조한 가치를 명료화했습니다.

By pooling all the votes and calculating the overall ratings of each professional value, we elucidated the values most emphasized by participants, such as humanism, communication, accountability, and ethics (Figure 3).

고찰

Discussion

"프로페셔널리즘 운동"을 관찰한 사회 학자들은 의학 교육자들에게 잠시 다음의 것을 성찰해보기를 권했다.

(1)누가 프로페셔널리즘의 개념과 속성을 결정하는가?

(2)이 가치들이 출현하는 과정은 어떠한가?16

Sociologists observing the “professionalism  movement” are challenging medical educators to pause and reflect on 

(1) who determines the concepts and attributes of professionalism and 

(2) the processes by which these values emerge.16

의학교육 문헌에서 프로페셔널리즘의 기존 정의는 주로 의사에게서 도출되며, 환자, 학생, 레지던트를 종종 포함하지만, 간호사가 포함 된 연구는 소수에 불과하다.

In the medical education literature, previous definitions of professionalism derive mainly from doctors,5,6,34 although some studies involved patients,35–37 students,35 and residents.36 Only a few studies included nurses.37

NGT는 한두 사람이 미치는 영향을 제한하고 모든 아이디어와 득표를 도출함으로써 전통적인 그룹 토의와 관련된 문제를 줄이는 것으로 나타났습니다. NGT의 이러한 특징은 연공 서열과 권위가 강조되는 대만과 같은 문화 환경에서 특히 유용합니다.

NGT has been shown to reduce problems associated with traditional group discussions by limiting the effect of dominating personalities and ensuring the elicitation of all ideas and votes. These features of the NGT are particularly useful in cultural settings, like Taiwan, where seniority and authority are emphasized.

언뜻보기에, 우리의 프레임워크은 서구와 약간의 유사점을 공유합니다.

At first glance, our framework shares some similarities with its Western counterparts.

NTUCM 체제와 스턴의 프레임워크 사이의 가장 현저한 차이점은 4 개의 기둥을 감싸는 빔으로서 "integrity"을 포함하기로 한 합의입니다. 히포크라테스 전통에 기초한 서구 체제가 환자의 우위를 강조하는 반면, 대만의 유교 전통은 다른 사람을 위해 integrity을 갖춘 사람이되어야한다고 강조한다. 공자는 이렇게 썼다. "선Virtuous한 사람은 무엇이든 또는 무엇이든 마음을 정하지 않습니다. 그는 옳은 것을 따를 것이다"

The most striking difference between the NTUCM framework and Stern’s framework is the consensus among our expert committee to ensure the addition of “integrity” as the beam capping the four pillars. Whereas Western frameworks based on the Hippocratic tradition stress the primacy of patients, the Confucian tradition of Taiwan emphasizes that one should become a person with integrity in order to serve others. Confucius39 wrote,

“The virtuous man, in the world, does not set his mind either for anything, or against anything; what is right he will follow.” 

유교 윤리의 서양 철학과 마찬가지로, 유학자들은 integrity가 있는 사람은 유혹과 혼란 속에서도 윤리적 인 선택을 할 것이라고 믿는다. 전문가위원회는 대만 맥락에서 유교 전통이 히포크라테스 전통보다 강력하기 때문에 integrity의 개념을 집중적으로 배치했다.

Similar to Western philosophies of virtue ethics, Confucians believe that people with integrity will make ethical choices even under temptation and confusion. The expert committee placed the concept of integrity centrally in our framework because the Confucian tradition is more powerful than the Hippocratic tradition in the Taiwanese context.

몇 가지 항목은 쉽게 통합되지 않았습니다. 이 항목들은 다른 사람들에 대한 진지한 관심을 나타내는 휴머니즘의 범주에 적합하지 않았으며 대신 의사의 개인적 삶과 직업적 삶의 균형에 관심이있었습니다. 서구의 프로페셔널리즘 틀이 환자의 우선성을 강조하고, 의사와 전문인의 개인 생활을 분리하는 반면, 유교 문화 전통은 이 둘의 조화를 지원support합니다.

a few items were not easily incorporated. These items did not fit in the category of humanism, which denotes a sincere concern for others, and were instead concerned with the balance between physicians’ personal and professional lives. Whereas Western professionalism frameworks emphasize the primacy of patients and separate physicians’ professional and personal lives, Confucian cultural traditions support the harmony of these roles.

유교 사상에서 한 사람의 위치는 사회적 역할에 의존적이지는 않더라도 분리될 수 있는 것이 아니다. 따라서 우리는 개인적 가치뿐만 아니라 전문적인 가치를 설명하는 "living framework"을 만들었습니다. 우리는 프로페셔널리즘 틀을 설계함에 있어서 사회적 책임 외에도 개인적인 책임을 인정하는 빈 공간을 의도적으로 포함시켰습니다. 구조화된 체계 속에 유연한 공간이 존재한다는 것은, 의사의 프로페셔널리즘이 사회가 정의한 핵심 원칙에 기초하고 역동적이며, 시간이 지남에 따라 개인의 성장에 responsive하다는 현실을 의미합니다.

In Confucian thinking, the position of the self is inseparable from, if not dependent on, one’s social roles. Thus, we created a “living framework” that accounts for individual as well as professional values. We designed our professionalism framework intentionally to include empty space, which acknowledges personal responsibility in addition to social responsibility. The presence of flexible space amidst the otherwise structured scheme signifies the reality that a physician’s professionalism is both grounded and dynamic—based on core principles defined by society, but also responsive to personal growth over time.

8 역량 프레임 워크로 분류 된 여러 항목은 대만의 오래 된 문화적 의미와 일치합니다. 예를 들어, 우리는 zi zhong의 개념 (존엄성을 가지고 자신을 수행함)을 "integrity"로 분류했습니다. Zi zhong은 중국 문화에서 오랜 전통을 가지고 있습니다. 중국의 전통 문화에서는 self-dignified or self-respecting이 유교 학자 또는 공무원이되기위한 첫 걸음 중 하나임이 널리 받아 들여지고 있습니다.

Multiple items categorized into the eight- competency framework align with deep cultural meanings in Taiwan. For example, we categorized the concept of zi zhong (conducting oneself with dignity) into “integrity.” Zi zhong has a long tradition in Chinese culture. In traditional Chinese culture, it is widely accepted that to be self- dignified or self-respecting is one of the first steps toward becoming a Confucian scholar or official.

自重

zì zhòng

to conduct oneself with dignity 

to be dignified

NGT 참가자들에 의해 제기된 이 개념은 우리 문화에 깊은 곳에 뿌리를두고 있으며, 기존의 서구 프로페셔널리즘 문헌에 기술된 "integrity"보다 더 많은 무게를 지니고 있습니다 .1-7,33-38

This concept, also raised by the NGT participants, is deep-rooted in our culture and carries more weight than “integrity” as it is described in existing Western professionalism literature.1–7,33–38

프로페셔널리즘을 위한 NTUCM의 프레임워크를 구축 한 후, 우리 기관에서 우리 프레임 워크의 핵심 가치를 홍보하기 위해 몇 가지 조치를 취했습니다.

After constructing NTUCM’s framework for professionalism , we took several steps to promote the core values of our framework at our institution.

우리의 교육 병원에서 서구의 프로페셔널리즘 틀을 채택하려는 기존 노력은 교사나 학생에게 잘 받아 들여지지 않았습니다. Cruess 등이 제안한 것처럼 "프로페셔널리즘을 가르치려면, 지역 관습과 가치를 존중하면서 다른 문화와 사회적 계약과 관련이 있어야한다"고 제안했다.

a previous effort to adopt a Western framework of professionalism at our teaching hospital was not well received by teachers or students. As Cruess et al43 suggest, “when professionalism is taught, it should be related to the different cultures and social contracts, respecting local customs and values.”

결론적으로, 이 연구는 서구 의학 전문기구의 보편적 응용성에 의문을 제기하며, 지역의 문화와 이해관계자의 가치를 반영하는 프로페셔널리즘 틀 구출 과정을 제안한다.

In conclusion, this study challenges the universal applicability of the Western frameworks of medical professionalism  and proposes a process to build a professionalism framework that reflects the cultural heritage and the values of local stakeholders.

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Acad Med. 2011 Nov;86(11):1407-14. doi: 10.1097/ACM.0b013e31823059d1.

Does one size fit all? Building a framework for medical professionalism.

Ho MJ1, Yu KH, Hirsh D, Huang TS, Yang PC.

Author information

1

Department of Social Medicine, National Taiwan University College of Medicine, Taipei, Taiwan. mjho@ntu.edu.tw

Abstract

PURPOSE:

Medical professionalism has gained global attention over the past decade, but there is a paucity of literature on the universal applicability of the dominant professionalism framework developed in the West. This study proposes an institutional approach to build a framework for medical professionalism that incorporates historical and sociocultural contexts.

METHOD:

From 2008 to 2009, the authors adopted nominal group technique (NGT) to determine professional competencies valued by 91 critical stakeholders of medical education (divided into 12 discipline-specific groups) at their institution and in their native society, Taiwan. An expert committee subsequently constructed a framework for professionalism which accounted for a literature review and their understanding of the institution's values and historical roots. To confirm that the framework encompassed the attributes nominated by NGT participants, the authors analyzed transcripts of NGT exercises to refine the final document.

RESULTS:

Each of 12 NGT groups raised 5 to 23 core competencies and determined the most important five competencies by summing participants' ratings of each item. The expert panel reached consensus on a framework that included eight competencies. The frameworkdiffers from the Western framework in the centrality of self-integrity, harmonizing personal and professional roles. Text analysis of the NGT transcripts demonstrated that the framework successfully incorporated top-ranked NGT results.

CONCLUSIONS:

This study challenges the universal applicability of the Western framework of medical professionalism and proposes a process to build a professionalism framework that reflects the cultural heritage and the values of local stakeholders.

PMID:

 

21971298

 

DOI:

 

10.1097/ACM.0b013e31823059d1

[Indexed for MEDLINE]