의학지식의 기본에 대해서 다시 생각해보기 (CanMEDS)

(출처 : http://www.royalcollege.ca/portal/page/portal/rc/resources/aboutcanmeds)

INTRODUCTION

지난 100년간 서양의 의학교육은 의학을 의생명과학으로 만들었다. 진료(=의학의 수행)는 가장 최신의 의학지식을 객관적으로 적용하는 것이 되었다.

For the last 100 years, Western medical education has constructed medicine as biomedical science. Over that time, scientific discoveries and medical breakthroughs have changed the face of medical practice. Biomedical research has flourished within medical schools, and non-clinical bench science in particular has become a major part of many of their missions.1–3 The practice of medicine has come to be understood as the objective application of the most advanced medical sciences to patient care; such medical sciences, in turn, have been limited to those which produced bioscientific knowledge. 

이에 따라 의학교육도 진료에 필요한 생명과학을 학습하는 것 위주로 구성되었다. 많은 사람들이 의학에는 'art'적 측면도 있다고 말했지만, 그럼에도 불구하고 의사가 된다는 것은 거의 전적으로 방대한 양의 생명과학 지식을 학습하는 과정이 되어갔다.

Medical education thus has become a predominantly bioscientifically oriented preparation for practice, with medical schools assuming the tasks of both producing biomedical knowledge and creating a curriculum to teach future doctors to practise within this bioscientific framework. Although many recognise that there is also an ‘art’ to the practice of clinical medicine, becoming a doctor continues to entail, almost exclusively, the acquisition of large amounts of bioscientific knowledge. 

생명과학지식이 의료에 많은 이득을 가져다 준 것은 분명하지만, 이것만이 의학교육의 유일무이한 기초는 아니다. 플렉스너는 물론이고, 최근에도 과학 지식을 강조하는 것과 미래에 의사를 키워내는 것의 연관성에 의문을 제기하는 보고서가 나오고 있다. 

Certainly scientific knowledge has brought large benefits to patients in clinical practice, but it is not the only foundation necessary for medical education. Flexner himself, often cited in defence of scientism, did not think scientific knowledge on its own constituted adequate medical training.2,4–6 More recently, reports7,8 and academic publications2,6,9–11 have questioned the exclusivity of the link between the emphasis on scientific knowledge in medical schools and teaching future doctors what they will actually need to know in order to practise medicine. The history of medical education also reminds us that the current generic medical curriculum is not the inevitable result of perfect understanding of how to train future doctors. 

역사적으로 사회적, 정치적, 경제적 힘이 의학교육에 작용해왔고 교육과정을 만들고 변화시켰다. 의학 커리큘럼은 "어떤 것이 되어야 하는 것"이 아니라 "현재 요구되는 것"이다.

Rather, it is the historically mediated result of the social, political and economic forces acting on medical education and its institutions over the time the curriculum was created and modified.12 This realisation that the medical curriculum is not ‘what must be’, but only ‘what is currently’, means that the structure and contents of the curriculum can change to concur with changing conceptions of its goals and objectives. 

현재 역량있는 의사에게 요구되는 다양한 영역은 무엇인가?

We are therefore obliged to ensure that the medical curriculum contains the appropriate kinds of knowledge doctors-in-training need to achieve what is currently believed to be competence. Implications of competency frameworks It is now widely accepted that there are multiple domains in which doctors are required to be competent. 

이러한 역량은 의사가 갖춰야 할 자질에 대한 의학교육자의 의견일 뿐만 아니라, 사회가, 대중이, 환자가, 가족이 요구하는 것이다.

It is not sufficient for doctors to have biomedical knowledge and technical skills. They must also, for example, be able to communicate well, to act in a professional manner and to work effectively with doctor and non-doctor colleagues. These competencies not only represent what medical educators and the medical profession as a whole believe to be important; they also reflect what the public, including patients and their families, want their doctors to be.

CanMEDS 역량은 이러한 것 중 하나이다. EFPO프로젝트로 만들어졌다. 

For example, the CanMEDS competencies (Fig. 1),13 one of the earliest and perhaps best known of the national competency frameworks, arose out of a series of public consultations in Ontario (the most populous Canadian province) in the 1980s.14 That public process and subsequent professional stakeholder consultations, all part of the Educating Future Physicians for Ontario (EFPO) project, identified the doctor roles which then became the CanMEDS competencies unveiled in 2000.15 

Other English language competency frameworks have similar claims to professional and public consultation or support.16–18 The societal expectations of doctors identified and drawn upon in such documents are, of course, as much the historically mediated outcomes of social, political and economic forces as the medical curricula with which they interact. Nonetheless, these frameworks can be seen to be (and are often presented as) surrogates for the current shared understanding between medical professionals, educators and patients about what doctors should be by the end of their training.

RESULTS 

Students educated in the foundational knowledge necessary for competence in all doctor roles would need to be exposed to ideas and ways of thinking from a wide array of disciplines outside the traditional biomedical sciences. These would need to be introduced in context and in ways that would support future medical practice. They would also broaden students’ understanding of the nature of legitimate medical knowledge.

CONCLUSIONS 

There are currently major gaps between the goals and objectives of competency frameworks such as CanMEDS and the actual contents of medical curricula. Addressing these will require curricular transformation to add knowledges, in context and in ways that positively affect practice, from disciplines not currently present within the medical school. In order to accomplish this, we will need to engage with colleagues throughout the university

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Med Educ. 2011 Jan;45(1):36-43. doi: 10.1111/j.1365-2923.2010.03791.x.

Rethinking the basis of medical knowledge.

Kuper A, D'Eon M.

Source

Department of Medicine, University of Toronto, Toronto, Ontario, Canada. ayelet94@post.harvard.edu

Abstract

CONTEXT:

Twentieth-century medical education constructed medicine as biomedical science. Although bioscientific knowledge has brought large benefits to clinical practice, many have questioned the appropriateness of its domination of the medical curriculum. As the content of that curriculum is itself a historically mediated social construct, it can be changed to fit current descriptions of the competent doctors medical schools are expected to produce. Such doctors are expected not only to have biomedical expertise, but also to carry out multiple other roles as described in competency frameworks such as that of CanMEDS. Many of these other roles are socio-culturally based and thus not supported by bioscientific knowledge.

METHODS:

We designed a thought experiment to delineate the need to identify and integrate the range of foundational knowledges required to support the development of doctors capable of performing all the roles described in the competency frameworks. We specified assumptions and demarcated our scope. To illustrate our ideas, we selected examples from the medical curriculum that linked to non-Medical Expert roles and outlined the disciplines that supported them.

RESULTS:

Students educated in the foundational knowledge necessary for competence in all doctor roles would need to be exposed to ideas and ways of thinking from a wide array of disciplines outside the traditional biomedical sciences. These would need to be introduced in context and in ways that would support future medical practice. They would also broaden students' understanding of the nature of legitimate medical knowledge.

CONCLUSIONS:

There are currently major gaps between the goals and objectives of competency frameworks such as CanMEDS and the actual contents of medical curricula. Addressing these will require curricular transformation to add knowledges, in context and in ways that positively affect practice, from disciplines not currently present within the medical school. In order to accomplish this, we will need to engage with colleagues throughout the university.

© Blackwell Publishing Ltd 2010.

Comment in

• Broad church or bunfight? Possibilities for progress in medical education. [Med Educ. 2011]