모든 이해관계자를 위한 핵심 역량 평가 프로그램 만들기: 선박 설계와 건조에서 얻을 수 있는 것( Adv Health Sci Educ Theory Pract. 2020)

모든 이해관계자를 위한 핵심 역량 평가 프로그램 만들기: 선박 설계와 건조에서 얻을 수 있는 것( Adv Health Sci Educ Theory Pract. 2020)
Building a core competency assessment program for all stakeholders: the design and building of sailing ships can inform core competency frameworks 
W. Dale Dauphinee1,2

유럽 산부인과학회 및 산부인과학대학(EBCOB)의 반 데르 아아(van der Aa) 등은 Advances 최신호에서 대학원 임상 교육에서 핵심 역량 기반 의학교육을 설계하는 데 필요한 대안 전략을 제시했습니다(반 데르 아아 등, 2019). 가장 중요한 것은 제목에서 알 수 있듯이 논리적이고 상향식 방식으로 진행되었다는 점입니다: 처방에서 지침까지: 일반 역량을 위한 유럽 프레임워크. 지난 20년 동안 의학교육 문헌에서 역량 교육에 대해 방대한 분량을 할애한 것을 감안할 때, 왜 처음부터 다시 시작했을까요? 그 이유는 역량 기반 교육(CBE) 및 평가(CBA)를 둘러싼 현장의 혼란스러운 상황에 대한 훌륭한 소개에 잘 설명되어 있습니다. 이는 특히 대학원 임상 교육에서 더욱 그렇습니다. 이에 대응하여 그들은 교육자를 전문 분야별로 안내하도록 설계된 단계별 경로를 개략적으로 설명했으며, 더 쉬운 학습과 더 많은 창의성을 위한 유연성을 거의 제공하지 않는 CBE 및 CBA의 경직된 목표를 사용하는 것을 피했습니다. 특히 산부인과(OB-GYN) 역량 기반 교육의 핵심 문제를 관리하고 구현하는 방법에 초점을 맞추기 위해 두 가지 주요 이니셔티브에 착수했습니다. 첫째, 의료 기관의 기본 운영 핵심 또는 기술 구조 내에서 일하는 의료 전문가들 사이에서 변화를 도입하고 확립하기 위한 모범 관리 사례를 검토하고 확인했습니다. 둘째, 다양한 일선 이해관계자와 대상 전문가들의 더 넓은 시각을 통해 산부인과에 필요한 일반적인 역량에 대한 보다 포괄적이고 새로운 초상을 포착하기 위해 액션 리서치 결과를 활용하여 새로운 프레임워크에 정보를 제공하고 채웠습니다. 두 가지 모두 축하드립니다.
In the current issue of Advances, van der Aa et al. from the European Board and College of Obstetrics and Gynaecology (EBCOB) have presented a needed and alternative strategy for designing core competency-based medical education in post-graduate clinical training (van der Aa et al. 2019). Most importantly, they have proceeded in a logical and bottom up manner, as clearly implied in the title: From Prescription to guidance: a European framework for generic competencies. Given the vast number of pages devoted to competency education in the medical education literature over the last two decades, why have they started from scratch? The reasons are well described in their excellent introduction on the muddled state of the field surrounding competency based education (CBE) and assessment (CBA). This is particularly true in graduate clinical training. In response, they have outlined a step-wise pathway designed to guide educators in a specialty specific manner and avoided using rigid objectives for CBE and CBA that offer little flexibility for easier learning and more creativity. Critically, they undertook two major initiatives in order to focus on how to manage and implement core issues in competency-based education in Obstetrics and Gynecology (OB-GYN). They reviewed and identified the best management practices for introducing and establishing change amongst health professionals working within the basic operative core or the technostructure of health care institutions. Secondly, they have looked through the wider lens of various front line stakeholders and targeted professionals to capture a more inclusive and refreshing portrait of the generic competencies needed in OB-GYN by utilization the results of action research to inform and populate a new framework. Congratulations on both counts.

그러나 제 의견을 공식화하고 뒷받침하는 데 도움이 되도록, 저는 예전에 목조 범선을 건조하고 장식하던 부모님의 가족으로부터 빌린 비유를 제시하고 싶습니다. 모든 이해관계자의 요구와 기대를 충족하기 위해 실제 일상 세계에서 작동해야 하는 제품이나 서비스를 만들려는 모든 이니셔티브와 마찬가지로, 목조 범선을 만드는 과정에는 여러 개별적이지만 서로 연결된 단계가 포함됩니다. 이러한 모든 단계는 성공적인 결과와 원하는 효과를 얻기 위해 필수적입니다.

• 즉, 선박의 주요 목적을 가장 적절하게 달성할 수 있도록 설계 및 건조하고(속도를 내기 위해 좁거나 큰 하중을 싣기 위해 넓게),
• 바람을 최적으로 포착하기 위한 '도구'로서 돛대, 리깅 및 돛을 설계 및 설치하며,
• 마지막으로 각 설계 가정과 후속 실행의 신뢰성과 타당성을 모두 검증하기 위해 해상 시험을 실행하는 것입니다.
• 궁극적인 목표는 설계자와 건조자가 이해관계자가 의도한 선박에 대한 비전과 열망을 충족했음을 입증하는 것입니다(Herreshoff 1974).

However, to help formulate and undergird my comments, I want to offer a metaphor borrowed from my parents’ families as builders and outfitters of wooden sailing ships in earlier times. Like any initiative in which one seeks to create a product or service that has to function in the real everyday world in order to meet all stakeholder’s needs and expectations, the creation of a wooden sailing ship involved several discrete but interconnected steps. All of these steps are essential for a successful outcome and the desired impact. They are:

• design and build the ship to most appropriately achieve its primary purpose (narrow for speed or wide for large loads),
• design and install the masts, rigging and sails as ‘instruments’ to optimally capture the wind; and
• lastly execute the sea trials to validate both the reliability and validity of each of the design assumptions and their subsequent execution.
• The ultimate goal is demonstrate that the designers and builders have met the stakeholders’ intended vision and aspirations for the ship (Herreshoff 1974).

선박 건조 프로세스에는 평가 프로세스 및 도구 구축에 직접적으로 영향을 미치는 특징이 있습니다. 새로운 설계는 일반적인 역량에 대한 이전의 시도에서 쉽게 드러나지 않았던 이슈와 문제를 정의하고 명확히 해야 합니다. 은유는 비교뿐만 아니라 중요한 통찰력도 제공합니다. 은유는 일련의 프로세스가 표현되는 방식에 관한 것입니다. 따라서 각 단계가 프로젝트의 전체 여정에 필수적인 아이디어나 품질을 상징하고 더 나은 결과와 더 큰 영향력을 얻기 위해 어떻게 진행하고자 하는지에 대한 스토리를 제공하기 위해 은유가 선택됩니다.
The ship building process has features that directly bear on the building of assessment processes and tools. A new design must define and clarify issues and problems that were not readily apparent in earlier attempts at generic competencies. The metaphor provides comparisons but also important insights. A metaphor is about how a set of processes is expressed. Thus, a metaphor is chosen to offer a story, within which each step symbolizes an idea or quality that is essential to the project’s overall journey and how they intent to proceed to a better outcome and greater impact.

저자의 접근 방식
The authors’ approach

반 데르 아아의 글은 이 새로운 전략을 성공적으로 마무리하기 위해 해결해야 할 일련의 개발 문제 중 첫 번째 단계에 대해 설명합니다. 아직 해야 할 일이 많이 남아 있습니다. 예를 들어, 핵심 역량을 파악하는 아이디어는 새로운 것이 아닙니다. 1999년에 미국의학전문위원회(ABMS)와 미국의학전문대학원교육인증위원회(ACGME)는 ABMS 역량 유지 프로그램 및 대학원 교육 수련 프로그램 인증의 기반이 될 6가지 핵심 일반 역량을 공동 승인하면서 이 개념을 장려했습니다. 6개의 광범위한 역량을 일련의 평가 요소로 분해한 다음 일련의 도구로 재구성해야 한다는 개념은 큰 도약이자 위험한 일이었습니다. 품질 개선을 지원하는 인프라를 구축하지 않으면 이러한 형식은 '제도화'는 되지만 '전문화'는 되지 않는 경향이 있습니다(Audet 외. 2005). 목록과 규칙만으로는 충분하지 않습니다. 
The van der Aa article describes the first step in a cascade of developmental issues that must be addressed in moving this new strategy to a successful conclusion. Much more remains to be done. For example, the idea of identifying core competences is not new. In 1999, the American Board of Medical Specialties (ABMS) and the Accreditation Council for Graduate Medical Education (ACGME) promoted the concept with their joint endorsement of six core general competencies to serve as the bases for the ABMS Maintenance of Competence program and for the accreditation of post-graduate education training program. The notion of six broad competencies having to be deconstructed into set of assessment elements and then reconstructed into a set of tools was a major leap and risky. Without the building of infrastructure to support quality improvement, such formats tend to be ‘institutionalized’ but not ‘professionalized’ (Audet et al. 2005). Lists and rules are not enough.

그러나 EBCOB 개발의 경우, 저자들은 행동 연구를 사용하여 일반적인 역량 프레임워크를 개발했습니다. 연구팀은 이해관계자 매핑을 활용하여 이해관계자 그룹과 협력하여 네 가지 영역을 식별했습니다.

• 환자 중심 치료,
• 팀워크,
• 시스템 기반 진료,
• 개인 및 전문성 개발

그러나 각 영역에서 '지침'을 제시하기보다는 이해관계자가 파악한 '요구사항'의 예를 설명하여 평가자가 '지침 표준'을 현지 상황에 적용할 때 더 나은 지침을 제공할 수 있도록 했습니다. 또한 평가자가 현장에서 재창조하고 창의적으로 적응할 수 있는 기회를 제공하기 위해 네 가지 영역을 일반적인 용어로 설명했습니다. 이 전략이 주는 시사점은 무엇인가요? 
However, in the case of EBCOB development, the authors used action research to develop a guiding generic competency framework. Utilizing stakeholder mapping, the research team worked with the stakeholder groups to identify four domains. They were

• patient- centered care;
• teamwork;
• systems-based practice; and
• personal and professional development.

However, under each domain, rather than offering ‘directives’, they described examples of the stakeholder’s identified ‘needs’ so as to offer better guidance to assessors when applying the ‘guiding standard’ to local contexts. Furthermore, the four domains were described in general terms so as to offer the evaluators the opportunities for re-invention and creative adaptation in the field. What are the implications arising from this strategy?

s10459-019-09910-8.pdf

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세 가지 즉각적인 과제가 있습니다. 프레임워크가 프로그램 디렉터, 학습자 및 교수진을 위해 최적으로 작동하려면 표준 보고 형식, 데이터 시스템 및 성과 데이터 수집을 위한 대시보드 액세스(예: 표준화된 항해 차트와 항해 육분계 및 기압계 데이터)를 설계하고 구현하는 것이 필수적입니다. 교수진을 준비하고 교육하기 위한 교수진 개발 프로그램과 연계된 품질 관리 프레임워크가 분명히 필요할 것입니다. 또한 학회와 이사회는 교수진이 사용할 수 있는 용어집과 허용되는 시험 형식을 제공할 수 있도록 해야 합니다. 저와 제 동료들은 품질 관리의 중요성과 핵심 역량 기반 교육 이니셔티브의 변경 사항을 감독하는 책임 있는 기관의 필요성을 설명했습니다(도피니 외. 2019). 우리는 모든 평가 노력의 장기적인 지속 가능성을 보장하기 위해 더 나은 품질 관리를 가능하게 하는 경로와 프레임워크를 제공했습니다. 우리도 이러한 다음 개발과 현장 테스트('해상 시험')를 기대할 것입니다.
There are three immediate challenges. The design and implementation of standard reporting formats, data systems and access to dashboards for the collection of performance data (i.e. standardized navigation charts plus data from navigation sextants and barometers) is essential if the framework is to function optimally for the program directors, the learners and teaching staff. Clearly a quality control framework, in association with a faculty development program to prepare and train the faculty, will be needed. That will also require the Society and Board to ensure that a glossary of terms and acceptable testing formats will be available for the teaching faculty. My colleagues and I have described the importance of quality control and having a responsible authority overseeing any changes in core competency-based education initiatives (Dauphinee et al. 2019). We offered pathways and frameworks to enable better quality control to ensure long-term sustainability of any evaluation endeavour. We too will look forward to these next developments and their field testing (‘sea trials’).

고려해야 할 다른 과제
Other challenges that should be considered

그러나 최근 역량 모델에 고려되지 않은 또 다른 위협이 있습니다. 의사의 번아웃 문제는 대학원 교육과 개업 의사 커뮤니티에서 우려할 만한 문제가 되었습니다. 미국 의학 연구소(IOM)의 최근 보고서인 '임상의 소진에 대한 조치 취하기'를 참고하세요: 전문직의 웰빙을 위한 체계적인 접근법이라는 보고서는 전문직의 모든 분야에서 관심을 기울일 것을 요구합니다(미국 과학, 공학 및 의학 아카데미 2019). IOM 보고서의 저자들은 의사 소진의 증가를 20년 전 '인간은 실수할 수 있다' 및 '질적 격차' 보고서의 결과와 동일한 수준의 대중적 관심사 및 조치의 필요성에 놓았습니다. 이 문제는 미국에만 국한된 것이 아닙니다. 이 비극적인 상황과 가능한 전략을 다루는 데 있어 반 데어 아아 보고서와 직접적인 연관성이 있습니다. However, there is another recent threat to any competency model that has not been considered. The challenge of physician burnout has become a worrisome issue within post-graduate education and the practicing physician communities. The recent report of the Institute of Medicine (IOM), Taking Action Against Clinician Burnout: A Systematic Approach to Professional Well-Being, demands the attention from all sectors of the profession (National Academies of Sciences, Engineering, and Medicine 2019). The IOM report’s authors have placed the rise in physician burnout on the same level of public concern and need for action as the findings from the To Err is Human and the Quality Chasm reports of 20 years ago. The issue is not confined to the USA. In addressing this tragic development and possible strategies, there is a direct link to the van der Aa paper.

EBCOB의 프레임워크에 따르면 네 가지 일반 역량 중 하나는 '개인 및 전문성 개발'입니다. 기본 원칙 중 두 가지는 '일과 삶의 균형'과 '개인의 역량과 한계 인식'입니다. 이해관계자 및 기타 전문가를 대상으로 한 액션 리서치 조사를 통해 이 핵심 역량을 파악한 것은 1990년부터 1998년까지 제가 컨설팅 자문위원으로 참여했던 온타리오 의사의 미래 교육(EFPO) 프로젝트를 떠올리게 합니다. 이 보고서에서는 의료 전문가, 커뮤니케이터, 협력자, 건강 옹호자, 학습자, 관리자("게이트키퍼"), 학자, "인격체로서의 의사" 등 미래의 의사에게 필요한 8가지 핵심 역할을 확인했습니다(Neufeld 외. 1998). 이러한 역할은 문헌 검색, 이해관계자, 환자, 그리고 의사와 학생에 대한 구조화된 인터뷰를 기반으로 확인되었습니다. 25년 전의 인터뷰와 연구는 다른 사람을 돕고 치유하는 전문가로서의 의사의 역할 외에도 한 인간으로서의 의사의 역할이 중요하다는 것을 시사했습니다. 이는 주목해야 할 주요 관심사였습니다. 실제로 EFPO 보고서는 온타리오주 의과대학에 졸업생들이 인격체로서의 의사를 포함한 이러한 역할을 수행할 수 있도록 홍보하고 준비하도록 했습니다. 나중에 캐나다 왕립 의사 및 외과의사 대학에서 이러한 역할을 CanMEDS 역할에 맞게 조정할 때 원래 이해관계자의 의견에도 불구하고 인간로서의 의사는 삭제되었습니다. CanMDES 역할 프레임워크는 국제적으로 널리 채택되었지만, 현재 CanMDES 웹사이트의 '인격체로서의 의사'는 '전문가로서의 의사' 아래에 '환자 치료를 촉진하기 위해 의사와 건강 및 복지에 대한 헌신을 보여야 한다'는 작은 언급을 제외하고는 다시 나타나지 않고 있습니다. 

Under the EBCOB’s framework, one of the four generic competences is ‘personal and professional development’. Two of the underlying the guiding principles are ‘balance work and life’ and ‘recognize personal competencies and limits’. The identification of this core competency from the action research enquiry of stakeholders and other professionals is reminiscent of Future Education of Physicians for Ontario (EFPO) project, for which I was a consulting advisor from 1990 to 1998. The report identified eight (8) core roles for the physician of the future: medical expert, communicator, collaborator, health advocate, learner, manager (“gatekeeper”), scholar, and “physician as person” (Neufeld et al. 1998). Of interest, the identification of these roles was based on literature searches, structured interviews of stakeholders, patients, and of course, physicians and students. The interviews and research from 25 years ago suggested that the physician, as a person, was important, in addition to the physician roles as expert to help and heal others. It was a major concern in need of attention. In fact the EFPO report committed the faculties in Ontario to promote and prepare their graduates for these roles, including physician as a person. Later, when the these roles were adapted by the Royal College of Physicians and Surgeons of Canada for the CanMEDS roles, physician as person was dropped despite the original stakeholder input. The CanMEDS roles framework was widely adopted internationally, but its current version on the CanMEDS Web-site, ‘physician as person’, has not reappeared, except for a small reference under ‘physician as professional’ to ‘demonstrate a commitment to physician and health and well-being to foster patient care’.

의사의 소진이라는 주요 문제와 그에 따른 다른 사람들이 인격체로서의 의사에 대한 원래의 잘 연구된 EFPO 역할에 주의를 기울이지 않는 것을 고려할 때, EBCOB 팀은 일반적인 '개인 및 전문성 개발' 역량을 다시 검토할 수 있을 것입니다. 이 영역이 새로운 도전 과제인 의사 및 전공의의 소진과 중도 탈락 문제를 해결하는 데 어떻게 사용될 수 있는지 고려할 수 있는 기회가 될 것입니다. IOM 보고서는 임상의의 소진과 직업적 웰빙에 대한 시스템 모델을 제안하며, 이를 고려할 가치가 있습니다. 분명 시스템 문제도 중요하지만, 최근 유럽의 산업보건 문헌에서 직무-제작에 관한 Bakker와 동료들의 연구도 앞으로 고려할 가치가 있습니다(Tims 외. 2013). 직무 제작은 인사 고문이나 멘토가 직원이 자신의 업무나 책임 또는 직장 내 다른 사람들과의 상호 작용을 맞춤화할 수 있는 수단을 고려할 수 있는 접근 방식입니다. 조직은 보건 직종을 포함하여 직무의 의미를 높이고 성과를 개선하기 위해 직원들에게 직무 제작을 수행하는 방법을 교육할 수 있습니다. 따라서 보건 서비스에서 개인의 역할이나 업무를 재설계하는 것은 하향식 직위 재설계에 대한 좋은 대안이며 유연성과 창의성이 더 높은 EBCOB 전략에 잘 맞을 수 있습니다. 앞으로 더 많은 규제와 더 많은 책임이 요구되는 상황에서 더욱 중요해질 것으로 보입니다. 더욱 실망스러운 것은 현장 테스트가 제대로 이루어지지 않은 인공지능 '보조 장치'가 의사의 개인 임상 루틴에 점점 더 많이 침투하고 있다는 점입니다. EBCOB 핵심 역량을 새롭게 살펴보는 것은 수련의가 자신의 업무 환경을 재정의하고 더 잘 통제할 수 있는 능력을 강화할 수 있는 추가적인 학습 전략을 고려할 수 있는 기회입니다. 이러한 후자의 고려 사항은 미래의 유럽 의사들에게 흥미롭고 생산적인 기회가 될 수 있습니다.
Given the major issue of physician burnout, and the subsequent failure of others to heed the original, well studied EFPO role on physician as person, the EBCOB team may want to revisit the generic ‘personal and professional development’ competency. It would be an opportunity to consider how this domain might be used to address an emerging challenge—the physician and post- graduate trainee problems of burnout and drop-out. The IOM report proposes a systems model of clinician burnout and professional well-being that deserves consideration. Clearly systems issues are important, but the recent work of Bakker and colleagues on job-crafting in the occupational health literature in Europe also deserves consideration going forward (Tims et al. 2013). Job crafting is an approach wherein personnel advisors or mentors can consider the means by which an employee can customize their tasks or responsibilities or interactions with others at work. Organizations can train their staff on how to undertake job crafting to increase their meaning and improve their performance, including in the health professions. Thus, the redesign of an individual’s roles or tasks in the health services is a good alternative to top-down position redesign and could fit nicely within the EBCOB strategy more flexibility and creativity. It would seem to be even more important in the future with more regulations and more accountability demands. Even more frustrating is the increasing penetration of artificial intelligence ‘aids’, often inadequately field tested, into the physician’s personal clinical routines. A fresh look at the EBCOB core competencies is an opportunity to consider additional learning strategies to amplify trainees’ abilities to redefine and take more control of their work environment. These latter considerations could be exciting and productive for the future physicians of Europe

결론적으로 이 보고서는 지속적인 전략 개발의 첫 번째 단계이며, 이를 위해 훌륭한 출발점이라고 할 수 있습니다. 기기 개발('장비 및 돛')과 현장 테스트('해상 시험')를 통해 아직 더 많은 작업이 필요한 문제가 밝혀진 후에도 이 이니셔티브를 개선할 기회가 더 많이 있습니다. 모든 규제 기관의 모토는 대중을 보호하고, 남녀노소를 막론하고 전문직을 선도하는 것이어야 합니다.
As a concluding comment, this report is the first step in an on-going strategic development, and to that end, it is an excellent start. There are many more opportunities to improve the initiative after instrument development (‘rigging and sails’) and after field testing (‘sea trials’) reveal what issues still need more work. Their mantra should be that of all regulatory organizations: protect the public and guide the profession, young and old.

 

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Adv Health Sci Educ Theory Pract. 2020 Mar;25(1):189-193. doi: 10.1007/s10459-020-09962-1. Epub 2020 Feb 6.

Building a core competency assessment program for all stakeholders: the design and building of sailing ships can inform core competency frameworks

W Dale Dauphinee 1 2

Affiliations

1Clinical and Health Informatics Research Group, Division of Clinical Epidemiology, Department of Medicine, McGill University, 1140 Pine Avenue West, Montreal, QC, H3A 1A3, Canada. dale.dauphinee@mcgill.ca.

2Foundation for Advancement of International Medical Education and Research, Philadelphia, PA, USA. dale.dauphinee@mcgill.ca.

PMID: 32030572

DOI: 10.1007/s10459-020-09962-1

Abstract

When educators are developing an effective and workable assessment program in graduate medical education by employing action research and stakeholder mapping to identify core competency domains and directives, the multi-stage process can be guided and informed by utilizing the story of designing, building and sea-testing sailing ships as a metaphor. However, the current challenge of physician burnout demands additional attention when formulating medical training frameworks, assessment guidelines and mentoring programs in 2020. The possibility of job-crafting is raised for consideration by designers of core competency frameworks in the health professions.

Keywords: Action research; Change management; Competency-based assessment; Generic competencies; Implementation; Job-crafting; Physician burnout; Post-graduate medical education.