의과대학생 구성의 다양성이 갖는 교육적 장점 : 학생 설문

Educational Benefits of Diversity in Medical School: A Survey of Students

Dean K. Whitla, PhD, Gary Orfield, PhD, William Silen, MD, Carole Teperow, Carolyn Howard, MEd, and Joan Reede, MD, MPH

지난 30년간 소수자 학생들이 대학과 대학원에 진학하는데 있어서 배키판결은 큰 영향을 주었다. 1978년 판결이 내려졌을 때 Supreme Court가 결정을 내린 근거 중 하나는 모든 학생들의 교육적 경험에 있어서 학생의 다양성이 중요하다는 것이었다. 법원은 '인종'을 학생을 선발하는 다양한 요인 중 하나로 보았으며, '정원'을 활용하는 것은 금지하였다. 그러나 일부 주에서, 그리고 5th District Court지역에서는 대학 입학에 있어서 인종에 대한 제한을 두고 있다. affirmative action을 비판하는 사람들은 affirmative action이 백인에게 공평하지 못할 뿐만 아니라, 애초에 기대했던 교육적 효과도 거두지 못하고 있다고 주장한다.

(The Bakke case : 배키 판결: 소수인종 학생을 입학시키기 위해 우수한 백인 학생의 입학을 거부한 것은 위헌이라는 판결)

The Bakke case has influenced admissions of minority students to college and graduate schools for the past three decades.1 In its 1978 ruling, the Supreme Court rested its decision on the importance of a diverse student body for the educational experience of all students. The Court stated that race could legally be considered only as one of a number of factors in selecting a class but forbade the use of quotas. However, in some states (California, Florida, Georgia, and Washington) and in the 5th District Court area (Louisiana, Mississippi, and Texas) both ballot initiatives and lower court decisions have placed restrictions on using race as a factor in higher education admission decisions. Critics of affirmative action argue not only that affirmative action is unfair to whites but also that such polices have not produced the educational gains for students that were anticipated.2,3

이 연구는 다양성의 교육적 효과에 대한 새로운 이해를 열기 위한 노력이라 할 수 있다. 이는 특히 의학교육에 대한 것이며, 2002년 12월 Supreme Court가 affirmative action admission정책을 리뷰하면서 이 분야 연구 중요성이 더 높아졌다.

This study represents an effort to add a new level of understanding to the educational effects of diversity, especially in medical education. The December 2002 decision of the Supreme Court to review affirmative action admission policies enhances the importance of these research efforts.

[중요]학생 다양성이 높은 경우 학생들이 서로 정보를 교환하고 서로의 가치 체계를 공유함으로서 문화적 민감성의 토대를 키울 수 있다. affirmative action이 의과대학 입학에 갖는 주요한 장점은 의료전달체계를 취약한 인구집단까지 확장시킴으로서 개개인의 의사에게 돌아가는 혜택을 넘어서는 사회적 이익을 창출한다는 점이다. 여러 연구에서 URM의사들이 더 소수의, 가난한, Medicaid인구를 돌본다는 것이 보고된 바 있다. 또한 북미의 소수민족들은 같은 민족의 의사를 찾아 가는 경향이 많으며, 이는 지역적인 이유 때문이라기보다 그들이 받는 서비스, 즉 상호 이해와 신뢰에 기반한 서비스, 때문이다. 같은 인종의 의사에게 진료를 받은 African-American 환자들이 의사를 평가할 때 좀 더 참여적으로 의사결정을 내린다고 평가하였다. 또한 의료만족도는 얼마나 환자가 의사의 지시를 잘 따르는가에 달려있기 때문에, 연구자들은 URM의사의 수를 늘리는 것이 다른 모든 의사들의 문화적 역량을 키우는 것을 넘어서서 그 소수인종들의 건강을 더 개선하는데도 도움이 될 것이라고 생각하고 있다. Jordan Cohen의 말을 빌리자면, 현재 AAMC의 president의 anti-affirmative action은 전 국가적 건강에 도움이 안 된다고 할 수 있다.

A diverse student body enables students to exchange information and share value systems of different cultures as a basic foundation for cultural sensitivity.4 A major benefit of affirmative action in medical school admissions is the ability to expand health care delivery to traditionally underserved communities, generating social benefits that go beyond the individual physician.5 Research indicates that underrepresented minority (URM) physicians are more likely to serve minority, poor, and Medicaid populations than are their majority counterparts.6,7,8 Moreover, minorities in North America tend to choose physicians of their own races, due not only to geographic location but also to the nature of the care they receive—care based on mutual understanding and trust.9,10 African American patients who see physicians of their own race tend to rate their physicians' decision-making styles as more participatory.11 Because satisfaction with health care is positively associated with patients' treatment compliance, researchers believe that increasing the pool of URM physicians, and improving cultural competence among all physicians, may lead to better health outcomes for minority populations.12,13 To paraphrase Dr. Jordan Cohen, current president of the Association of American Medical Colleges, anti-affirmative action would be bad for our collective national health.13

METHOD

데이터 수집은 매우 어렵다. 전화 인터뷰 활용.

Data collection from medical students, because of their complicated and overloaded schedules, is very difficult. Of the various methods of data collection—e-mails, personal interviews, questionnaires, telephone interviews—we decided from prior experience with surveys of law students at eight U.S. law schools 14 and the Bowen and Bok research effort,15 that telephone interviewing was the most effective method of collecting responses. The deans of the two participating medical schools, Dean Debas of the University of California, San Francisco, School of Medicine and Dean Martin of Harvard Medical School, approved of the project. Their representatives provided telephone numbers of each school's enrolled undergraduates. The Harvard Committee on the Use of Human Subjects approved the project. We employed The Gallup Organization to the complete phone interviews. Although a phone call even from a professional polling organization does not guarantee anonymity, research conducted using this method has normally been sanctioned as meeting this qualification. As such, “implicit informed consent” meets the review standards of the two medical schools.

전문가가 설문 작성

A committee with expertise in questionnaires and medical education constructed the survey instrument, drawing on previous work in this area. Previous questionnaires by the National Science Foundation, the American Medical Association, the Canadian Federation of Medical Students, and the Institute of Ethics were examined. The instrument, a series of five-point Likert-type questions asking students to rate the importance of diversity in the student body in a number of areas, was pilot tested with a small group of graduate students in the medical sciences. “Diversity” was defined for students as being limited to racial and ethnic diversity. The construct validity of the instrument was deemed appropriate and adequate from the pretest results and by the oversight of a team of psychometricians and medical educators. The internal consistency of the series of items focusing on attitudes toward diversity was found to be substantial (Cronbach's alpha = .87).

갤럽 설문조사 

In May and June of 2000, Gallup interviewers phoned students enrolled in all four years of the Harvard and UCSF medical schools. Interviewers made up to five calls per student, and if no contact occurred, that instance was deleted from the total number. The response rate, taking into account these deletions, was 97%. However, due to the infrequency of actual student contact, only 55% of the total enrolled student body at both schools could be sampled. Interviewers also recorded students' explanatory remarks in response to the questions.

총 데이터 수집 

Our data represent the views of 639 students, 338 from Harvard and 301 from UCSF. The responders consisted of roughly equal numbers of students in each of the four years of medical school study. The response patterns and the demographics of the Harvard and UCSF medical students were not found to be significantly different. Therefore, the responses from the two samples were combined in the analyses. The racial and ethnic characteristics of the UCSF and Harvard samples were also typical of the total enrolled student populations at the two schools (chi-square test p = .87). Furthermore, the composition of the combined sample did not differ from the U.S. population of enrolled medical school students (chi-square test p = .71). There were 2% more African Americans in the study sample than were enrolled nationally (9% versus 7% nationally); 6% more Asians (26% versus 20% nationally); 3% more Latinos (9% versus 6% nationally); 0.3% fewer Native Americans (0.5% versus 0.8% nationally); and 10% fewer others (56% versus 66% nationally). Approximately 93% of those surveyed (597 students) were U.S. citizens, and just over 6% (42) were foreign nationals. Because the sample was representative of the enrolled students at UCSF and Harvard and the U.S. medical school population, there may be some inferences that can be drawn from the findings that have national implications.

RESULTS

• Interactions with Those of Different Race or Ethnicity
• Classroom Dynamics
• Impact of Diversity on Policy Matters

DISCUSSION

 

두 가지 중요한 결론.

There are two important findings in this study. 

다른 인종과 민족을 만날 기회가 대학교 때보다 그 전에 더 부족하다. 이는 의과대학에서 더 컸다. 인터뷰를 했을 때 60%를 넘는 학생들이 3명 이상의 가까운 다른 인종/민족 친구가 있다고 응답하였다. 이러한 관계와 우정이 후에 의술을 행할 때 매우 중요할 것이다.

First, students typically had less contact during their formative years with those of different races and ethnicities than they did during their college years. Student cross-cultural and cross-racial interactions increased even more during medical school. When interviewed, over 60% of the students stated that they had three or more close friends who differed racially and ethnically from themselves. Such collegial relationships and friendships are critical given the multicultural society in which they will later practice medicine.

두 번째 결론은 하버드와 UCSF 모두에서 학생의 다양성이 의과대학에서의 학습경험을 더 향상시켜줬다고 응답하였다. 이러한 현재의 affirmative action policies를 유지할 것을 지지했다.

The second and perhaps even more important finding is that both Harvard and UCSF students reported that the interaction with a diverse student body greatly enhanced their educational experiences in medical school. These students strongly supported maintaining or strengthening current affirmative action policies in admissions at their respective schools.

학생들은 이러한 다양성으로부터의 장점을 잘 이용하려고 노력하고 있다. 학장들은 학생들이 준비가 덜 되어있다고 응답하고 있고, 교육과정에서 충분히 다뤄지지 못하고 있으며, 전문의학회에서도 강조하고 있다. 다양성은 교실 내에서 토론의 폭을 넓히고, 교육적 기반을 확장한다.

The frequency with which the majority of students study with those from different racial groups suggests that students attempt to take advantage of the diverse student body medical school provides. The consistently low numbers of minority faculty in medical school compounded with the dearth of cultural sensitivity training suggests that students' interactions—both inside and outside the classroom—provide one of the few arenas in which students can gain cultural awareness before they mingle with a multicultural patient population. 

In a recent poll of 98 medical schools, many school deans felt that their recent graduates were only “somewhat prepared” to provide culturally sensitive clinical care.18 Although cultural competence is included in some medical curricula, it is too often a rather sterile course taught from a syllabus. Medical students and faculty from diverse racial and ethnic backgrounds teach each other about the cultures, beliefs, and values of their communities.4,16 Indeed, the core curriculum guidelines of the Society of Teachers of Family Medicine, approved by the Academy of Family Physicians, recognize the need to teach respect and tolerance for cultural and social class differences in a pluralistic society by setting forth a three-tier approach: attitude, knowledge, and skills development.19 Diversity among students clearly improves the breadth of class discussion, a fundamental educational benefit and a basis for learning culturally competent health care.

학생들은 서로 중요한 이슈에 대해서 가르친다는 가설을 지지하는 결과 역시 있는데, 생화학이나 해부학 교육에는 해당되지 않을 수 있지만, 아시아 학생은 미국 학생으로부터 배우고, 이렇게 서로의 문화에 대한 이해가 나중에 의사가 되어서 환자의 compliance향상에도 도움이 될 것이다.

That students gave high ratings for a diverse student body supports the hypothesis that students regularly educate each other on important issues, such as differences among the cultures and how to best respond to those differences. The teaching dynamic in a biochemistry or anatomy class may be less affected by the racial and ethnic diversity of students. However, students' understanding of patients and colleagues is likely to be affected when, for example, an Asian student learns from a Native American student about tribal views of healing. Furthermore, treatment compliance may be positively affected if, for example, a Caucasian student from an affluent, predominantly Caucasian suburb learns from an African American inner-city colleague how to better engage African American inner-city patients in following a course of treatment through the public health clinic.

 

현재 입학정책에 갖는 affirmative action의 의의도 살펴볼 필요가 있다. 학교마다 주는 가중치가 많이 다르며, 과거에 남성위주의 학생에서 여성이 다수를 차지하는 상황으로 잘 이행해왔다. 비슷한 변화를 인종/민족 구성에서도 이룰 수 있다.

For medical schools to accomplish the goal of increasing the diversity of the physician population to mirror that of the general population, the academic community will need to reconsider the current stand on affirmative action in admissions.20 

In a recent survey of 15 medical schools, researchers found that the weights given to qualitative factors such as URM status in the admission process vary widely from school to school.20 

However, the transition from a predominantly male profession to one today in which women make up a majority of medical students has been accomplished without compromising medical education in any way. Thus, it should be possible to make a similar shift in the racial and ethnic composition of students as well. 

Students in the present survey expressed in parenthetic remarks that there should be more socio-economic as well as racial and ethnic diversity in the student body. Looking at national demographics, one can see the opportunities to broaden the student base and, certainly, the need for physicians to become culturally competent.11,16

 

일부 부정적이며 우려스러운 의견을 보인 학생도 있었으나 다수는 지지하고 있었음. 많은 학생들이 '다양성'이 학교를 선택한 주요한 이유 중 하나라고 말했음.

Despite the support for a diverse student body and affirmative action in admissions, we should mention that a number of students responded to the open-ended question about affirmative action with statements about the importance of merit in the selection process (8% of total responses), and a few were concerned about standards. However, 57% of the students responding to the open-ended section gave responses that were overwhelmingly in favor of affirmative action in admissions, and these students further commented upon the need to continue using such measures. Many of the majority students mentioned that the diversity of students was one of the more important reasons in their choice of a school. They encouraged other schools that have not achieved such diversity to be more aggressive in recruiting URM students and expressed that it was a privilege to have been admitted to a school known for such efforts.

 

URM학생 중 누구도 '대변인'이 되어야 한다는 것의 부담이 있다고 응답하지는 않았음. 

None of the URM students expressed concern about being burdened with the mantle of “spokesperson” for their racial or ethnic groups. In our work with undergraduates, that reaction frequently occurs—more in response to classroom interaction—but it was absent in the responses in this medical school survey.

학생들은 매우 affirmative action을 지지하고 있었으며, 의과대학생의 다양성이  교육경험을 향상시키고 문화적으로 다양한 기회를 준다고 믿고 있었다. 서로 다른 인종/민족간 사이에 가까운 관계를 유지하고 있었으며, 이것이 의료를 더 잘 이해하고 나중에 더 잘 진료할 수 있게 해준다고 응답하였음.

In summary, students enrolled in Harvard and University of California, San Francisco, medical schools overwhelmingly supported affirmative action in admissions. They strongly believed that diversity enhanced their educational experiences and provided them with culturally rich opportunities. They had established close collegial and personal friendships with students of different races and ethnicities. These students stated that such ties contributed greatly to their understanding of medical practice and, ultimately, would better train them for service in a multicultural society.

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Acad Med. 2003 May;78(5):460-6.

Educational benefits of diversity in medical school: a survey of students.

Whitla DK1, Orfield G, Silen W, Teperow C, Howard C, Reede J.

Author information

Abstract

PURPOSE:

Many U.S. medical schools have abandoned affirmative action, limiting the recruitment and reducing the admission of underrepresented minority (URM) students even though research supports the premise that the public benefits from an increase in URM physicians and that URM physicians are likely to serve minority, poor, and Medicaid populations. Faculty and students commonly assume they benefit from peer cultural exchange, and the published evidence for the past two decades supports this notion. This research examined the students' perceptions of theeducational merits of a diverse student body by surveying medical students at two schools.

METHOD:

In 2000, medical students from all four years at Harvard Medical School and the University of California, San Francisco, School of Medicine were enrolled in a telephone survey about the relevance of racial diversity (among students) in their medical education. Students responded to the interviewer's questions on a five-point Likert-type scale.

RESULTS:

Of the 55% of students who could be located, 97% responded to the survey. Students reported having little intercultural contact during their formative years but significantly more interactions during higher education years, especially in medical school. Students reported contacts with diverse peers greatly enhanced their educational experience. They strongly supported strengthening or maintaining current affirmative action policies in admissions. The responses and demography of the Harvard and UCSF students did not differ significantly, nor did they differ for majority studentsand URM students-all groups overwhelmingly thought that racial and ethnic diversity among their peers enhanced their education.

CONCLUSIONS:

Diversity in the student body enhanced the educational experiences of students in two U.S. medical schools.

PMID:

 

12742780

 

[PubMed - indexed for MEDLINE]