정체성, 정체성 확립, 그리고 의학교육(2)

Oath of the Class of 2015 As I put on my white coat for the first time, I wholeheartedly devote myself to the medical profession. I pledge to serve with both compassion and creativity, keeping in mind that true healing can only come through care of the whole person, cura personalis. I will care for my patients with integrity and empathy. With a humble heart and an open mind, I vow not only to educate my patients, but also to learn from them in return. Never forgetting that trust must be earned, I will treat all people with dignity. 

My stethoscope connects my ears to my patients' hearts. In order to heal, I will listen to the needs of my patients, adapting to their unique cultural values. I will tirelessly advocate for my patients, with the understanding that the health of the individual is reflected in the wellbeing of the community. I shall strive to build bridges through communication and sensitivity. 

Soon, the pockets of my coat will overflow with the instruments of healing. So too, will I gather the knowledge and experience required to deliver the highest level of care. I will seek out the wisdom of my colleagues and be an active voice through collaboration and innovation. As my coat becomes worn, I will forever remain a passionate student of medicine. 

As a member of the Albert Einstein College of Medicine Class of 2015, I pledge to live this oath.

(출처 : http://www.einstein.yu.edu/features/stories/711/the-sworn-identity-einsteins-first-years-create-their-own-oath/)

정체성은 고정된 스키마가 아니다. '무슨 행동을 하는가'가 곧 정체성이다. 

정체성은 끊임없는 상호작용을 통해서 나타난다. 

정체성은 우리가 다른 사람에게 우리의 이야기를 전할 때에도 드러난다.

어렵더라도 적절한 관계-중심적 교육이 필요하다. 

다른 사람들과의 상호작용 과정에서 linguistic ritual을 학습하게 된다.

우리 모두는 나름의 이야기를 가지고 있다. 

이 이야기를 이해하고, 발전시키는 것은 전문직업적 정체성을 성공적으로 발전시키는 핵심 요소이다. 

교육학적 공간(pedagogical space)를 제공하여 학생들이 스스로와 동료의 이야기를 통해서 의사로서의 정체성을 개발할 수 있게 해주는 것이 필요하다. 

"어느 조직이 하고 있는 것이 무엇이든, 그것은 구성원의 정체성을 만든다."

따라서 의과대학 학생들의 정체성확립 과정에서 중요하게 이해해야 할 것은, 

그 기관에서 학생들이 마주치게 될 '어떻게 일들이 이뤄지는가'의 모습이다. 

즉 의과대학학생을 전문직의 합당한 일원으로 받아주지 않는 것("너는 .... 할 때 까지는 진짜 의사라고 할 수 없어")은 심각한 결과를 가져올 수 있다.

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INTERACTIONAL RELATIONSHIPS

앞에서 강조된바와 같이, 정체성은 고정된 스키마가 아니다. '무슨 행동을 하는가'가 곧 정체성이다. 정체성은 끊임없는 상호작용을 통해서 나타난다. 우리는 어떠한 행동을 함과 동시에 다른 사람에게 어떻게 보여질지를 생각한다. 스스로 표방하는 정체성이 있으면서 다른사람이 생각하는 나의 정체성을 관리하고자 하는 것이다. 이같은 행동적 측면은 의식적일수도 있고 무의식적일 수도 있다. 

As highlighted above, identities are not fixed cognitive schemas; rather, identities are what we do. Identities are asserted and claimed through continual interactions; we seek to be and be seen to be as we attempt to manage others’ impressions of ourselves and the identities we claim.18 This performative and routine aspect of daily life is ever present and can be conscious or unconscious. 

지속적인 역할 연습을 통해서 학습된 생각과 행동(habitus)에 의해 영향을 받아 스스로를 드러내며, 이러한 관점은 언어의 자아 표현적 측면(performative aspect of the self)에서도 드러난다. 

Indeed, through continual role rehearsal, the presentation of the self is influenced by habitus (acquired patterns of thought and behaviour) and is unconscious.32 Therefore, this perspective places the focus on language as a performative aspect of the self, rather than on language as the externalisation of underlying mental processes or psychological states (e.g. motivations, traits, dispositions, attitudes etc.).

정체성은 우리가 다른 사람에게 우리의 이야기를 전할 때에도 드러난다. narrative identity라는 개념이 새로운 것은 아니지만, 어떻게 일단 형성된 정체성이 의미를 가질 수 있도록 다듬어지는지에 대한 이해를 도와준다.

Performative aspects of identity are also present in the stories we tell to others (and ourselves):  The concept of a narrative identity is not new, but it is a powerful way to understand how identities are shaped and re-shaped to make meaning,

정체성은 의학적 상호작용을 하고, 일상생활을 하는 과정에서 스스로와 다른 사람에 의해서 구성된다. 중요한 것은 정체성은 활동을 통한 관계적 측면에서 형성되고, 관계는 정체성확립의 행심적 요소라는 점이다. 또한 의과대학 학생들 각자가 지닌 개성과, 감성과 문화적 스토리가 스스로의 전문직업적 정체성에 영향을 준다는 것이 중요하다.

Thus, identities are constructed and co-constructed within medical interactional settings as we go about our daily work,7,9,10,37,38 and as we recount events of our experiences to ourselves and others.1,3,39,40 That the process of identification is situated in and through talk has wide-ranging implications within medical education. The main messages I wish to convey here are that, firstly, identities are developed within relational settings through activities, and relationships are central components of identification. And, secondly, medical students (and doctors) are people, individuals with their own personal, emotional and cultural stories which influence their professional identities.

이 두 가지 요소가 시사하는 점은, 무엇보다 어렵더라도 적절한 관계-중심적 교육이 필요하다는 것이다. 다른 사람들과의 상호작용 과정에서 linguistic ritual을 학습하게 된다. 이러한 교육은 의학을 바라보는 관점을 보여주고, 의사답게 생각하고 말하고 행동하도록 한다. 또한 이러한 교육이 '의사가 된다는 것은 무엇인가'에 대한 문화적 기대, 소위 hidden curriculum에 영향을 줄 수도 있다.

These two factors require much more attention that can be afforded here, but I will briefly mention implications for research and practice. Firstly, fostering appropriate relationship-centred educational practices is necessary, albeit a major challenge.41 Within interactional settings, linguistic rituals are learned. Linguistic rituals include particular language choices and the adopting of specific stances towards others. These rituals reflect a medical worldview that facilitates thinking, speaking and acting like a doctor. This process might inadvertently reinforce unwanted traditional cultural expectations of what it is to be a doctor (the so-called hidden curriculum) and run counter to developing new ways of doing things.

교육과정이 어떻게 미래 의사의 발전에 영향을 주는지를 보고 싶다면 다양한 상호작용 환경하에서 정체성이 어떻게 구성되고 확립되고, 적용되는지를 면밀히 살펴보아야 한다. 다양한 상호작용 환경에는 PBL이나 의사소통기술 훈련, 회진, 교육세미나, 그리고 비공식적 환경 같은 것들이 모두 포함될 수 있다.

If we want to know how our curricula impact on the development of tomorrow’s doctors we must develop a sensitivity to the ways in which identities are constructed, enacted, invoked or exploited in a variety of interactional settings.43 These settings include problem-based learning sessions, communication skills training, ward rounds, teaching seminars and student participation in surgical settings, and even interactional exchanges in informal settings.

두 번째로 우리 모두는 나름의 이야기를 가지고 있다. 이 이야기를 이해하고, 발전시키는 것은 전문직업적 정체성을 성공적으로 발전시키는 핵심 요소이다. 교육학적 공간(pedagogical space)를 제공하여 학생들이 스스로와 동료의 이야기를 통해서 의사로서의 정체성을 개발할 수 있게 해주는 것이 필요하다. 이것은 많은 학생들이 훈련을 받는 과정에서 루틴하게 하는 반성적 과정과는 다르다. 좀 더 상호작용적인 측면이 필요하며, 다양한 의미를 발견해내고 학생들이 그들이 누구이고, 누구여야 하는지에 대한 이해를 할 수 있도록 촉진시켜줘야 한다.

Secondly, we all have our story. Understanding and developing this story is essential to the successful development of our professional identity. Providing the ‘pedagogical space’37 to facilitate students’ sense making processes through their narrative telling and re-telling of clinical experiences, thereby enabling them to understand their own developing identities as doctors, is essential in medical education. Indeed, this goes beyond the individual reflective practice that many students routinely undertake as part of their training. A more interactional context is required, within which multiple meanings are explored, facilitating students’ own understandings of who they are and who they might be.

As highlighted above, identities are not fixed cogni- tive schemas; rather, identities are what we do. Identities are asserted and claimed through continual interactions; we seek to be and be seen to be as we attempt to manage others’ impressions of ourselves and the identities we claim.18 This performative and routine aspect of daily life is ever present and can be conscious or unconscious. Indeed, through continual role rehearsal, the presentation of the self is influenced by habitus (acquired patterns of thought and behaviour) and is unconscious.32 Therefore, this perspective places the focus on language as a performative aspect of the self, rather than on language as the externalisation of underlying mental processes or psychological states (e.g. motivations, traits, dispositions, attitudes etc.).

 

Performative aspects of identity are also present in the stories we tell to others (and ourselves): as we try to make sense of events our identities emerge as we story our individual experiences, positioning our- selves to cultural and social expectations.33 The concept of a narrative identity is not new, but it is a powerful way to understand how identities are shaped and re-shaped to make meaning, to provide a sense of coherence to our lives34 and to guide our actions.35 Moreover, narratives that instantiate identities are not just found in the ‘big stories’ we tell of our lives, but can be seen in fleeting moments of ordinary conversational contexts.9,10,19,36

 

Thus, identities are constructed and co-constructed within medical interactional settings as we go about our daily work,7,9,10,37,38 and as we recount events of our experiences to ourselves and others.1,3,39,40 That the process of identification is situated in and through talk has wide-ranging implications within medical education. The main messages I wish to convey here are that, firstly, identities are developed within relational settings through activities, and rela- tionships are central components of identification. And, secondly, medical students (and doctors) are people, individuals with their own personal, emotional and cultural stories which influence their professional identities.

 

These two factors require much more attention that can be afforded here, but I will briefly mention implications for research and practice. Firstly, foster- ing appropriate relationship-centred educational practices is necessary, albeit a major challenge.41 Within interactional settings, linguistic rituals are learned. Linguistic rituals include particular language choices and the adopting of specific stances towards others. These rituals reflect a medical world- view that facilitates thinking, speaking and acting like a doctor. This process might inadvertently reinforce unwanted traditional cultural expectations of what it is to be a doctor (the so-called hidden curriculum) and run counter to developing new ways of doing things. For example, patient-centred care has been advo- cated to replace doctor-centred care as it facilitates more favourable outcomes. Despite successfully developing this stance in students during their pre- clinical years, Year 3 students have shown a progres- sive trend towards doctor-centred attitudes during their initial clinical year.42

 

If we want to know how our curricula impact on the development of tomorrow’s doctors we must develop a sensitivity to the ways in which identities are constructed, enacted, invoked or exploited in a variety of interactional settings.43 These settings include problem-based learning sessions, communi- cation skills training, ward rounds, teaching seminars and student participation in surgical settings, and even interactional exchanges in informal settings. As researchers we must be aware of the minutiae within interaction and must attend to aspects of talk that are embedded in the routine and rituals of everyday professional interactions.

 

Secondly, we all have our story. Understanding and developing this story is essential to the successful development of our professional identity. Providing the ‘pedagogical space’37 to facilitate students’ sense- making processes through their narrative telling and re-telling of clinical experiences, thereby enabling them to understand their own developing identities as doctors, is essential in medical education. Indeed, this goes beyond the individual reflective practice that many students routinely undertake as part of their training. A more interactional context is required, within which multiple meanings are explored, facilitating students’ own understandings of who they are and who they might be.

INSTITUTIONAL SETTINGS

"어느 조직이 하고 있는 것이 무엇이든, 그것은 구성원의 정체성을 만든다." '기관'은 정체성확립이 일어나는 가장 중요한 공간이다. 따라서 기관에 따라 구체적인 위계화된 세팅 안에서 특정 패턴의 행동이 정해지고, 어떻게 일이 되어야하는지가 정해진다. 

‘Whatever else organisations do, they do identification:’ 2 institutions are the most important places within which identification becomes consequential. Accordingly, institutions can be conceived as representing patterns of behaviour within specific hierarchical settings, signifying the way things are done: ‘Precisely because identities are constructed within, not outside, discourse, we need to understand them as produced in specific historical and institutional sites within specific discursive formations and practices, by specific enunciative strategies.’44 

따라서 의과대학 학생들의 정체성확립 과정에서 중요하게 이해해야 할 점은, 그 기관에서 학생들이 마주치게 될 '어떻게 일들이 이뤄지는가'의 모습이다. 의도하지 않아도 전달되게 되는 비공식적인 규칙, 암묵적 가치, 믿음, 태도 등이 여기에 포함된다.

Therefore, an important aspect of understanding the process of medical students’ identification is to pay particular attention to how things are accomplished within the specific institutional sites that they encounter. This includes paying attention to the unofficial rules and implicit values, beliefs and attitudes that may also be inadvertently conveyed.

한 기관에서 흔히 일어나는 것은 "일련의 의례"들이다. 한 정체성으로부터 다른 정체성으로 넘어가는 과정이 될 수 있으며, White Coat Ceremony가 그 중 하나이다.

Common phenomena within any institution are the ‘rites of passage’ which comprise part of the transition from one identity (imminent membership, legitimate peripheral participation) to another (authentic membership, full participation). For example, the White Coat ceremony,

그러나 좀 더 함축적인 의례들이 있는데, 비공식적인 ascription이다. 즉 의과대학학생을 전문직의 합당한 일원으로 받아주지 않는 것("너는 .... 할 때 까지는 진짜 의사라고 할 수 없어")은 심각한 결과를 가져올 수 있다.

However, there are other, more implicit rites of passage that medical students undergo (e.g. dissecting cadavers, working long hours) that are informal ascriptions to the profession. Indeed, the lack of informal ascriptions can indicate a rejection of professional identity for the medical student by legitimate members of the profession (a kind of ascriptive rejection: ‘You’re not a real doctor until you have...’) that can have serious consequences.

한 기관 안에서 전문직업적 정체성을 발전시키는 것은 그 기관의 문화에 영향을 줄 수도 있다. 우리는 임상 환경에서의 경험이 학생들의 학습에 얼마나 나쁜 영향을 줄 수 있는가가 연구된 바 있다. 하지만 그 반대도 있을 수 있다. 성공적으로 '어떻게 행동해야 하는지'를 학습한 학생은 후에 '실제로 일어나고 있는 일'이 그와 맞지 않았을 때 그것을 바꿔나갈 수도 있다.

Accordingly, the development of professional identities within institutional settings can impact on aspects such as cultural change. Indeed, we have seen how experiences within the clinical setting can have detrimental effects on students’ learning in the early years.42 However, the reverse may also be the case. Students who have successfully internalised aspects of the way things should be done within their medical school setting have the potential to later challenge the way things are done if those ways conflict.

정체성은 역사적인 관례를 보여주는 기관의 언어를 통해서 확립된다. 문화를 바꾸고자 한다면 역사적으로 병원의 진료가 어떻게 반복되어져왔고, 어떠한 작은 변화들이 있어왔으며 어떠한 도전을 받아왔고, 바뀌게 된다면 어떤 영향이 있을 것인가를 이해해야 한다.

Identities are constructed through language in institutional sites which have historical practices – the way things are. Medical educationists who wish to develop cultural change need to understand the intricate and nuanced ways in which historical practices are replicated, subtly changed and even challenged and the impact this might have for development.

As highlighted above, small acts of defiance have the potential to act as catalysts for cultural change. But do they? Can they change medical culture? We need to understand the ways in which new policies, as delivered through the medical curricula, are adopted and challenged.

‘Whatever else organisations do, they do identifica- tion:’2 institutions are the most important places within which identification becomes consequential. Accordingly, institutions can be conceived as repre- senting patterns of behaviour within specific hierarchi- cal settings, signifying the way things are done: ‘Precisely because identities are constructed within, not outside, discourse, we need to understand them as produced in specific historical and institutional sites within specific discursive formations and prac- tices, by specific enunciative strategies.’44 Therefore, an important aspect of understanding the process of medical students’ identification is to pay particular attention to how things are accomplished within the specific institutional sites that they encounter. This includes paying attention to the unofficial rules and implicit values, beliefs and attitudes that may also be inadvertently conveyed.

 

Common phenomena within any institution are the ‘rites of passage’ which comprise part of the transi- tion from one identity (imminent membership, legitimate peripheral participation) to another (authentic membership, full participation). For example, the White Coat ceremony, when performed for incoming medical students, explicitly signifies a transition into the medical profession through the conferring of this symbol of professional member- ship, albeit as a student member. This can be conceived as formal ascription to the medical pro- fession. However, there are other, more implicit rites of passage that medical students undergo (e.g. dissecting cadavers, working long hours) that are informal ascriptions to the profession. Indeed, the lack of informal ascriptions can indicate a rejection of professional identity for the medical student by legitimate members of the profession (a kind of ascriptive rejection: ‘You’re not a real doctor until you have...’) that can have serious consequences.

 

 

Accordingly, the development of professional identi- ties within institutional settings can impact on aspects such as cultural change. Indeed, we have seen how experiences within the clinical setting can have detrimental effects on students’ learning in the early years.42 However, the reverse may also be the case. Students who have successfully internalised aspects of the way things should be done within their medical school setting have the potential to later challenge the way things are done if those ways conflict. For example, small acts of resistance to the existing culture – so-called secondary adjustments – represent ways in which relatively powerless individuals protect their interests and identities.45

 

Within medical settings, as actors, students have the potential to act as role models for clinicians (e.g. students purposively washing their hands in front of clinicians who lack this rigor encourages clinicians to follow suit).

CONCEPTUALISING AND RESEARCHING IDENTITY IN MEDICAL EDUCATION

데이터 수집에 있어서 단 하나의 옳은 방법은 없다. 다른 모든 연구와 마찬가지로 가장 좋은 수집과 분석 방법을 활용해야 한다. 또한 모든 연구 질문이 먼저 떠오르지는 않으며, 어떤 질문은 데이터를 분석하는 중에 떠오를 수도 있다.

No single method of data collection or of analysis is ‘right’. As with any research, the most appropriate method of data collection and the best analytical tools can only be discerned from the specific research question itself. Furthermore, not all research questions are a priori; within qualitative research, sometimes new research questions emerge as we interrogate our data.

서로 다른 접근방법은 서로 다른 데이터 수집 방법에 따라서 서로 다른 의미를 가진다. 하지만 접근법들이 근본적 이념은 다를 수 있어도 언어적, 사회적 행동을 보고자 하는 측면에서는 동일하다.

Different approaches will necessarily have different implications on methods of data collection. However, although each of these approaches might differ in terms of its underlying ideologies (e.g. identity as an accomplishment of interaction, as (co)constructed in interaction, as shaped by societies’ dominant discourses, as historical processes, etc.), they converge insofar as they focus on language and social action.

우리는 데이터 수집과 해석을 더 창의적으로 해야 할 것이다.

One final point I wish to make in this section links with my assertion that we need to think more creatively about methods of data collection and interpretation. 

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Med Educ. 2010 Jan;44(1):40-9. doi: 10.1111/j.1365-2923.2009.03440.x.

Identity, identification and medical education: why should we care?

Monrouxe LV.

Source

Division of Medical Education, School of Medicine, Cardiff University, Cardiff, UK. monrouxelv@cardiff.ac.uk

Abstract

CONTEXT:

Medical education is as much about the development of a professional identity as it is about knowledge learning. Professional identities are contested and accepted through the synergistic internal-external process of identification that is constituted in and through language and artefacts within specific institutional sites. The ways in which medical students develop their professional identity and subsequently conceptualise their multiple identities has important implications for their own well-being, as well as for the relationships they form with fellow workers and patients.

OBJECTIVES:

This paper aims to provide an overview of some current thinking about identity and identification with the aim of highlighting some of the core underlying processes that have relevance for medical educationists and researchers. These processes include aspects that occur within embodied individuals (e.g. the development of multiple identities and how these are conceptualised), processes specifically to do with interactional aspects of identity (e.g. how identities are constructed and co-constructed through talk) and institutional processes of identity (e.g. the influence of patterns of behaviour within specific hierarchical settings).

IMPLICATIONS:

Developing a systematic understanding into the processes through which medical students develop their identities will facilitate the development of educational strategies, placing medical students' identification at the core of medical education.

CONCLUSIONS:

Understanding the process through which we develop our identities has profound implications for medical education and entails that we adopt and develop new methods of collecting and analysing data. Embracing this challenge will provide better insights into how we might develop students' learning experiences, facilitating their development of a doctor identity that is more in line with desired policy requirements.

Comment in

• Identities as performances: encouraging visual methodologies in medical education research. [Med Educ. 2010]
• Do you really want to be a doctor? The highs and lows of identity development. [Med Educ. 2012]