의학교육에 전문직업성 도입하기: 도입을 위한 도구로서의 평가

의학교육에 전문직업성 도입하기: 도입을 위한 도구로서의 평가

Embedding professionalism in medical education: Assessment as a tool for implementation

Baltimore, Maryland

May 15-17, 2002

학습환경의 전문직업성 문화를 향상시키려는 노력에 방해가 되는 것

For example, improvement in the "culture of professionalism" in learning environments is impeded or eroded by the following:

• Faculty behavior that can be unprofessional, destructive, and lasting (교수의 행동)

• Lack of support for training and tools to understand, communicate about, and resolve lapses and conflicts in professionalism (전문직업성에 대한 훈련, 이를 이해하기 위한 도구, 이를 위한 의사소통 등에 대한 지원부족)

• Lack of promotion of tenets and behavior related to professionalism (전문직업성과 관련된 보상의 부족)

• A practice of managing institutional lapses (cf, billing and human subjects issues) rather than rethinking systems for the reduction and prevention of lapses (조직에 과실이 발생했을 때, 시스템을 다시 생각해보고 그것을 줄이기 위해 노력하기보다는 그저 덮으려는 행동)

평가에 대한 연구의 방향을 설정하기 위한 몇 가지 권고사항들

Recent literature reviews, summarizing and adding to the work of others, offer a few basic recommendations for directions in assessment research that include18,19:

• Continuing the deconstruction and translation of definitions, attitudes, concepts, and elements into specific behaviors (정의, 태도, 개념, 요소등을 구체적인 행동으로 해체하고 번역하는 것)

• Investigating the hypothesis that assessment should focus on "behaviors as expressions of value conflicts [and conflict resolution], and on the contextual nature of professionalism behavior" (평가는 가치관의 충돌에서 발현되는 행동을 평가해야 하며, 전문직업성 행위의 맥락적 특성에 초점을 둬야한다는 것에 대한 조사)

• Using multiple methods and sources of information accumulated over time with multiple observations (긴 시간을 두고 여러 차례에 걸쳐 관찰을 통해 축적된 정보와 다양한 방법의 사용)

• Developing critical incident approaches that also include less severe and significant lapses (critical incident approaches를 사용하되 덜 심각하거나 덜 중요한 실수도 포함시키기)

• Attending to the crucial influence of the surrounding environment (주변 환경의 중대한 영향에 주의를 기울이기)

Implicit in these recommendations is a call for...

• (구체적인 관찰 가능한 행동의 목록이 필요함) a consensus catalog of detailed, specific, observable behaviors to serve as a basis for assessment; and 
• (지식 평가를 위한 표준화된, 객관적인 시험을 넘어서는 사고) a mandate to think beyond standardized, objective tests of knowledge that may be effective for assessing requisite foundations for or recognition of the principles of professionalism, but are ineffective for assessing actual behavior. 

Explicit in these recommendations is 

• '시험을 보는 방식'이 추론하는 것에 대한 경계 caution about inferences made from testing approaches which may or may not reflect reality, and in which students are aware that observation and assessment are taking place; 
• 평가는 전문직업성을 위한 하나의 수단에 불과하므로 총체적 시스템이 중요하다는 것 the importance of a comprehensive system's approach to espousing professionalism for which assessment is but one vehicle; and 
• 교수와 기관의 풍습에 의해 전해지는 가치에 관심을 둘 것 particular attention to values (positive and negative) transmitted by faculty and institutional mores.

Session 1: Behaviors Refecting Professionalism

Altruism

• Offers to help team members who are busy (바쁜 팀원 돕기)

• Contributes to the profession; active in local and national organizations such as the AAMC – Organization of Student Representatives (해당 직종에 대한 기여)

• Does not use altruism as an excuse to misprioritize or to rationalize certain behaviors ("I can't be with my family because my patients need me.") (특정 행동을 합리화시키기 위하여 이타심을 잘못 사용하지 않을 것)

Honor and Integrity

• Forthcoming with information; does not withhold and/or use information for power (권력을 위하여 정보를 숨기지 않을 것)

• Admits errors (실수를 인정할 것)

• Deals with confidential information discreetly and appropriately  (기밀 정보는 신중하고 적절하게 활용할 것)

• Does not misuse resources (eg, school computers and patient's food) (자원을 오용하지 않을 것(학교 컴퓨터, 환자 음식))

Caring and Compassion

• Treats the patient as an individual, taking into account lifestyle, beliefs, personal idiosyncrasies, support system (환자를 개인으로서 대하고, 생활습관/신념/개인적 특징/지지시스템 등을 고려할 것)

• Communicates bad news with sincerity and compassion (안 좋은 소식은 진심과 동정을 담아 의사소통할 것)

• Deals with sickness, death, and dying in a professional manner with patient and family members (질병과 사망은 환자 또는 환자의 가족과 전문가적인 자세로 다룰 것)

• Supports a balance in personal and professional activities for peers and subordinates (동료와 아래사람을 위한 개인과 전문직 사이의 균형을 잘 유지할 것)

Respect

• Respects institutional staff and representatives; respects faculty during teaching sessions (기관의 다른 스텝이나 대표를 존중할 것. 수업시간에는 교수를 존중할 것)

• Respects patient rights/dignity (privacy/confidentiality, consent); knocks on door, introduces self, drapes patients appropriately, and shows respect for patient privacy needs (환자의 권리/존엄을 존중할 것)

• Demonstrates tolerance to a range of behaviors and beliefs (다양한 행동과 신념에 대한 tolerance를 보일 것)

• Does not disturb small group sessions (소규모 세션을 disturb하지 말 것)

Responsibility and Accountability

• Demonstrates awareness of own limitations, and identifies developmental needs and approaches for improvements (스스로의 한계를 인식하고 발전을 위해 무엇이 필요한지, 향상을 위해 어떤 접근법이 필요한지 알 것.)

• Cares for self appropriately and presents self in a professional manner (ie, demeanor, dress, hygiene) (자신을 잘 돌보고, 프로페셔널한 매너(행실, 복장, 위생)로 자신을 소개하기)

• Recognizes and reports errors/poor behavior in peers (동료의 실수를 인식할 수 있고 보고하기)

• Informs others when not available to fulfill responsibilities and secures replacement (책임을 다하지 못하거나 자리를 지키지 못할 것 같은 상황에서 다른 사람에게 알리기)

• Takes responsibility for appropriate share of team work (팀 업무에서 적절한 부분에 대한 책임을 맡기)

• Arrives on time (제 시간에 도착하기)

• Accountable for deadlines; completes assignments and responsibilities on time (마감날짜 지키기)

• Answers letters, pages, e-mail, and phone calls in a timely manner (편지, 삐삐, 이메일, 전화 등에 적절한 시기에 응답하기)

Excellence and Scholarship

• Masters techniques and technologies of learning (학습을 위한 기술/기법 익히기)

• Is self-critical and able to identify own areas for learning/practice improvement (학습/실기 향상을 위해 스스로 필요한 부분을 찾아내기)

• Has internal focus and direction, setting own goals (스스로의 초점과 방향성을 가지고 스스로의 목표를 설정하기)

• Takes initiative in organizing, participating, and collaborating in peer study groups (동료와의 스터디그룹을 조직, 참여, 협동하기 위한 이니셔티브 가지기)

Leadership

• Teaches others (다른사람 가르치기)

• Helps build and maintain a culture that facilitates professionalism (전문직업성을 촉진하는 문화를 건설하고 유지하기)

• Does not provide disruptive leadership (eg, organizing pranks, inappropriately confronting authority figures) (파괴적 리더십 보이지 않기)

Sesion 2: From Behaviors to Assessment. 

The Purpose of Assessment

• A persistent theme throughout the conference was the purpose of assessment. The design of instruments and methods, and the supporting systems will vary substantively based on whether, for example, the purpose is to identify those at the bottom of the continuum as opposed to a continuous quality improvement model that provides feedback to everyone. Possible purposes include the following:

o Raising institutional awareness

o Improving patient care

o Improving patient perceptions

o Improving perceptions of students and faculty

o Identifying role models

o Rewarding good behavior

o Providing a vocabulary for communicating about professionalism

o Continuous quality improvement of individuals

o Identifying offenders

o Punishing unacceptable behavior

Environment

• An important end point of any professionalism activity must be to raise the awareness of faculty and students to issues of professionalism, and ultimately build and maintain an environment that supports the tenets of professionalism. Lack of awareness will impede the detection of patterns of lapses in professionalism and thus will limit their remediation. Better behavior can only follow increased awareness, richer understanding, and reinforcement by the culture.

• Activities related to professionalism (assessment in particular) must be supported by an environment of trust. Assessment should not engender, for example, feelings of paranoia ("I'm always being watched.") or perceptions of risk (for reporting aberrant behavior). This environment of trust is crucial to many agendas, including the airing of medical errors (in self and others) in a safe, constructive, and supportive environment that can facilitate individual and systems improvement.

A transformation may be required in the environment from one of risk management to risk reduction. The former may tend to obscure or discourage discussion of suboptimal actions,behaviors and outcomes, whereas the latter might facilitate open and non-punitive discussion of systems and methods for their improvement.

• Assessment should focus not only on individuals but also on programs, departments, and systems. Additional professionalism learning activities can then be built around information gleaned from aggregated assessment data.

Schools' Additional Obligations

• Schools must provide students with opportunities to model and demonstrate positive and exemplary professionalism behaviors (eg, leadership and volunteering)

• Schools must develop and communicate policies that make their expectations and values explicit, and provide tools and resources for students to improve their own professionalism performance.

The Boundaries for Observation

• Professionalism tenets should apply outside the traditional classroom or clinical setting. For example, unseemly behavior associated with administrative tasks (interactions with a school clerk responsible for loan documentation) is within the realm of professionalism to which schools should attend.

Conceptual Areas for Assessment

• Challenges to student professionalism may arise from emotionally charged situations, such as handling patients and families during death and dying experiences. Under these circumstances, behavior may generalize to other emotionally challenging situations; dealing with such situations effectively and reliably is a critical skill that must be learned in medical school. A developmental agenda might include building a scale of "emotional challenge" in interacting with patients (history taking at one end, dealing with a dying patient at the other) from which learning and assessment objectives could be derived.

Models for Feedback

• Use of assessment for formative feedback or continuous quality improvement should be encouraged, as should models for positive reinforcement (recognition and reward).

• The proper use of information derived from the assessment of professionalism requires additional deliberation. "Professionalism" is manifested in behaviors across a broad range of acceptability, and will vary for the same person across time and based on the environment and situation; extreme care should be taken to avoid labeling students. The point at which information is useful for punitive action rather than formative assessment is controversial and requires further debate.

Other Challenges in Implementation

• Implementing assessment systems requires caution to ensure that the systems do not create professionalism conflicts or other adverse unintended effects. For example, a potential conflict exists between the need for "institutions" to enforce "compliance" with professionalism tenets and the professional requirement for self-regulation without external intrusion.

• Challenges accompany different means for assessment and will require careful thought. For example, self-reporting of errors will result in vulnerability that requires a supportive culture.

Session 3: Approaches of particular interest

During the discussion of these approaches, a number of common implementation characteristics were identified:

• Instruction and assessment related to professionalism should be continuous across medical school and closely planned and integrated.

• Methods should provide recurrent feedback and, in the least, be used for formative assessment.

• Many if not all methods will require multiple observations and observers.

• Because of the nature of professionalism and the inadequacy of any one tool, numerous approaches should be used to reinforce importance and to ensure that sufficient information is compiled for the intended uses.

• Multiple instructional interventions will be required with supportive feedback.

• Professional behavior and the internalization of values must apply to everyone, including faculty, and are required for the success of the individual and institution, and for the welfare of patients.

Summation

Explicit and formal instruction and assessment of professionalism are essential to convey institutional values and prepare medical students for their societal contract. Yet, in a survey conducted only several years ago, a dozen schools had no formal instruction related to professionalism; almost half had no explicit methods for assessing professional behavior.25

Moreover, much has been written about the influence of factors other than explicit instruction and assessment on the development of professionalism, including the informal or hidden curriculum and related issues of behavioral

modeling.26,27,28

These issues were rife in conference deliberations. Stated more starkly by student and resident attendees (paraphrased here), "…We're being asked to be professional in an unprofessional environment. Faculty should be subject to the same criteria for assessment as students and residents." The message was clear in response that assessment and instruction tied to an explicit professionalism curriculum are necessary but not sufficient; they will be ineffective without an institutional commitment, beginning with its leadership, not only to encourage professional activity but to expect it. Indeed, models for institutional leadership exist wherein professionalism is actively promoted with, for example, highly visible recognition and reward systems.29 Additional exemplars of leadership demonstrating professionalism at an institutional level are needed. A national consensus on best institutional practices might be of great benefit. Also, institutional norms may need to be examined explicitly, perhaps through an institutional professionalism culture audit. Where appropriate, norms should be modified so that expected behaviors are supported by the culture. For example, a student's "asking for explanation or help when knowledge is inadequate" should not be perceived as a sign of weakness.

In closing, this conference convened individuals representing broad, varied, and sometimes divergent interests, expertise, and opinions in the assessment of medical student professionalism. Hopefully, it provides a framework for further detailing behaviors that can be the basis for assessment of professionalism, and ideas for expanding approaches to assessment. However, it is clear that other activities must accompany assessment for professionalism to be embedded in the medical environment. Faculty will require training, not only in explication of tenets of professionalism, assessing students, and providing feedback, but also in how to improve their own behaviors. Moreover, expectations for student professionalism will have to apply to faculty as well. An uncompromising expectation for professionalism must come directly from institutional leaders, and be encouraged, rewarded, and enforced throughout. Finally, these activities will require not only the continued dedication of researchers and medical school leaders, but also the coordinated multi-institutional efforts and the synchronous push of a broad array of national organizations.