의사소통과 대인관계 영역의 역량 평가하기: The Kalamazoo II Report

의사소통과 대인관계 영역의 역량 평가하기: The Kalamazoo II Report

Assessing Competence in Communication and Interpersonal Skills: The Kalamazoo II Report

F. Daniel Duffy, MD, Geoffrey H. Gordon, MD, Gerald Whelan, MD, Kathy Cole-Kelly, MS, MSW,

Richard Frankel, PhD, and All Participants in the American Academy on Physician and Patient’s Conference on Education and Evaluation of Competence in Communication and Interpersonal Skills

전공의 수련 프로그램에 대한 인증과 의사에 대한 자격부여를 위해서는 의사소통과 대인관계 기술 역량에 대한 평가가 필요하다. 전공의와 CME프로그램 관리자들은 이를 가르치고 평가하기 위한 방법을 찾아왔다. 이 보고서는 교육자들, 평가자들, 연구자들이 사용한 방법과 도구를 요약한 것이다. 

Accreditation of residency programs and certification of physicians requires assessment of competence in communication and interpersonal skills. Residency and continuing medical education program directors seek ways to teach and evaluate these competencies. This report summarizes the methods and tools used by educators, evaluators, and researchers in the field of physician–patient communication as determined by the participants in the “Kalamazoo II” conference held in April 2002.

 

의사소통과 대인관계 기술은 그 두가지가 합해져서 통합된 역량을 이룬다. 

Communication and interpersonal skills form an integrated competence with two distinct parts. 

• Communication skills are the performance of specific tasks and behaviors such as obtaining a medical history, explaining a diagnosis and prognosis, giving therapeutic instructions, and counseling. 
• Interpersonal skills are inherently relational and process oriented; they are the effect communication has on another person such as relieving anxiety or establishing a trusting relationship.

이 보고서에서는 의사소통과 대인관계 기술 평가를 위한 세 가지 방법을 정리하였다.

This report reviews three methods for assessment of communication and interpersonal skills: 

(1) checklists of observed behaviors during interactions with real or simulated patients; 

(2) surveys of patients’ experience in clinical interactions; and 

(3) examinations using oral, essay, or multiple-choice response questions. 

이들 방법은 교육 프로그램에 포함되어 피드백을 주기 위항 목적으로 사용되기도 하고, 같은 방법이 표준화되고 교사보다는 평가자에 의해서 사용되면 총괄평가가 된다. 

• These methods are incorporated into educational programs to...
• assess learning needs, 
• create learning opportunities, or 
• guide feedback for learning. 
• The same assessment tools, when... 
• administered in a standardized way, 
• rated by an evaluator other than the teacher, and 
• using a predetermined passing score, 
• => become a summative evaluation. 

The report summarizes the experience of using these methods in a variety of educational and evaluation programs and presents an extensive bibliography of literature on the topic.

 

환자와 의사와의 전문적 대화가 진단, 치료, 돌보는 관계 형성 등에 영향을 준다. 그리고 이들이 얼마나 성공적인가는 많은 부분 의사의 의사소통과 대인관계 기술에 달려있다.

Professional conversation between patients and doctors shapes diagnosis, initiates therapy, and establishes a caring relationship. The degree to which these activities are successful depends, in large part, on the communication and interpersonal skills of the physician. This report focuses on how the physician's competence in professional conversation with patients might be measured. Valid, reliable, and practical measures can guide professional formation, determine readiness for independent practice, and deepen understanding of the communication itself.

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몇몇 국가 기관들이 환자와 의사 사이 의사소통의 중요성을 인식하기 시작했다.

Several national organizations have recognized the importance of communication between doctors and patients. 

AAPP또한 컨퍼런스를 열었다.

Responding to these stimuli, the American Academy on Physician and Patient (AAPP) held a conference on patient-physician communication on April 7–9, 2002, at the Fetzer Institute in Kalamazoo, Michigan. 

open-space format을 활용하여 참가자들이 자신의 경험을 공유하고 그 결과를 요약하였다.

Using an open-space format, participants shared their experience with teaching and evaluating communication skills in a variety of settings and attempted to summarize the state of the art in teaching and evaluating competence in communication and interpersonal skills. 

의사소통과 대인관계 기술의 일반적 역량

General Competence in Communication and Interpersonal Skills

의사소통 기술

Communication Skills

환자와의 의사소통은 의료의 핵심 임상 기술이다. 구체적인 임무와 관찰가능한 행동의로 정의될 수 있다. 

Communication with patients is the core clinical skill for the practice of medicine.8 It can be defined as specific tasks and observable behaviors that include...

• interviewing to obtain a medical history, 
• explaining a diagnosis and prognosis, 
• giving therapeutic instructions and information needed for informed consent to undergo diagnostic and therapeutic procedures, and 
• providing counseling to motivate participation in therapy or to relieve symptoms.9,10

대인관계 기술

Interpersonal Skills 

의사소통 기술이 구체적인 임무와 행동이라면, 대인관계 기술은 본질적으로 관계와 절차에 대한 것이다. 대인관계 기술은 다른사람과의 의사소통 효과성에 초점을 둔다. 이 역량은 ABIM에 의해서 "humanistic qualities"라 묘사된 바 있다.

While communication skills are the performance of specific tasks and behaviors by an individual, interpersonal skills are inherently relational and process oriented. Interpersonal skills focus on the effect of communication on another person. This competency has been described as “humanistic qualities” by the American Board of Internal Medicine (ABIM).12 

대인관계 능력은 기본적인 의사소통 능력에 기반하지만, 그 자체로 충분하지는 않다. 대인관계 기술의 중요한 요소들은 다음과 같다.

 Interpersonal skills build on basic communication skills, which alone are insufficient to create and sustain a therapeutic relationship. Lack of interpersonal skills may help explain why patients’ experience of an encounter only loosely correlates with objective ratings of the physician's communication skills.13 Important elements of interpersonal skills include 

(1) respect, including treating others as one would want to be treated; 

(2) paying attention to the patient with open verbal, nonverbal, and intuitive communication channels 14; 

(3) being personally present in the moment with the patient, mindful of the importance of the relationship; and 

(4) having a caring intent, not only to relieve suffering but also to be curious and interested in the patient's ideas, values, and concerns.15 

엡스타인은 여기에 "flexibility", 즉 실시간으로 관계를 모니터하고 필요한 대인관계 기술을 적응하는 능력을 추가했다.

Epstein 16 adds flexibility, or the ability to monitor the relationship in real time and adjust interpersonal skills as necessary.

팀 내 의사소통

Communication in Teams

환자와의 상호작용은 의사소통과 대인관계의 단면일 뿐이며, 다른 중요한 것은 임상 팀에서의 것이 있다. 의사소통과 관련한 팀워크 역량에는다음과 같은 것들이 있다.

Interactions with patients form only one aspect of communication and interpersonal skills; other important aspects include clinical teamwork with peers, colleagues, and myriad others. Competence in teamwork communication includes...

• skill in speaking up against an authority gradient, 
• clarity in assuring the sequence of message sent–message received, and 
• attentiveness to roles and relationships, monitoring, and backup. 

의사소통과 대인관계 역량을 가르치고 평가하는 것은 항공 또는 핵에너지 같은 high-reliability industries 에서는 이미 흔한 일이었으나 의료 분야에서 관심을 갖기 시작한것은 비교적 최근이다.

Teaching and assessing communication and interpersonal competence is common in other high-reliability industries such as aviation and nuclear energy,19,20 but has only recently begun to be applied to medical teams.21,22 

의사소통과 대인관계 기술의 특수한 역량

Specific Competence in Communication and Interpersonal Skills

의사가 초심자부터 전문가까지 성장하는 과정에서 '역량'의 정의는 일반적인 의사소통 업무로부터 복잡하거나 부담스럽거나 전문과 특이적인 상황에서 잘 해내는 것까지 확대된다.

As physicians advance from novice to expert in the practice of a specialty, the definition of competence expands from performing generic communication tasks to successful performance in complex, demanding, and specialty-specific situations.23–25

Methods for Assessing Communication and Interpersonal Skills

기본적으로 평가에는 세 가지 방법이 있다.

There are three basic methods for assessing communication and interpersonal skills: 

(1) checklists of observed behaviors in interactions; 

(2) surveys of patients’ experience in interactions; and 

(3) examinations using oral, essay, or multiple-choice response questions.

Use of Assessment Tools in Teaching and Evaluation

체크리스트는 형성평가에서 다양한 목적으로 사용 가능하고, 같은 도구라도 방법을 바꾸면 총괄평가에서 사용할 수 있다. 같은 평가도구를 형성평가와 총괄평가에서 같이 사용하는 것에는 다음과 같은 장점이 있다.

Teachers can use checklists to assess learning needs, create learning opportunities, or guide feedback and coaching; this is formative evaluation.68 The same assessment tool, when administered in a standardized way, rated by an evaluator other than the teacher, and using a predetermined passing score, becomes a summative evaluation.69 There are advantages in using the same assessment tool for both formative (teaching) and summative (high-stakes) evaluations. 

• First, teachers and evaluators can agree on the content and rating of the skills. Consequently, the goals for learning and the content of the assessment will be the same.  (교수자와 평가자가 동일한 목표를 가지게 된다)
• Second, by identifying and demonstrating the skills and providing students opportunity to practice the skills while receiving feedback, they will understand the skills to be learned and be prepared to demonstrate the skills during evaluations. (학생은 최종 평가에서 어떤 것을 배워야하고 준비해야하는가를 피드백 과정에서 알 수 있다.)
• Third, the assessment tool (or its component parts) can be used across a variety of teaching settings, including supervised patient encounters. Figure 1 shows how one type of assessment tool (a checklist for rating performance) provides an operational definition of the goal for learning and what a satisfactory performance involves. The checklist guides faculty observation and focuses feedback to help the student learn new patterns of performance. The most effective approach to teaching and evaluating communication and interpersonal competence involves a program of multiple methods of assessment.28 (평가 도구, 또는 한 도구의 일부는 다양한 교육 세팅에서 사용될 수 있다. 의사소통과 대인관계에서 가장 효과적인 교육/평가 방법은 다양한 평가 방법을 사용하는 프로그램이다.)

평가 도구의 특성

Characteristics of Assessment Tools

 

All assessment tools possess certain psychometric characteristics. These include 

(1) reliability—the measurement will produce the same result when repeated after a short interval, and that ratings of the same behavior by different individuals will produce the same result; 

(2) validity—the tool accurately measures the performance it intends to measure; 

(3) generalizability—the degree to which performance in this particular context predicts performance in other contexts; and 

(4) credibility—the power of the measurement to support or change the organizing beliefs and actions of the one being assessed.(평가자가 속해있는 조직의 신념이나 행동방식을 지지하거나 변하게 만들어주는 평가도구의 힘)

어떤 평가도구를 사용할것인가는 다음의 것들에 달려있다.

• The stakes of the evaluation determine the requirements for the psychometric rigor of the measurement. 
• Apart from psychometric standards, financial and human costs are significant factors in determining which measurement tools are used. 
• The realistic financial and human constraints notwithstanding, at a minimum, evaluation of competence in communication skills should be based on direct observation by persons who competently perform these skills.

구체적 평가 도구들

Specific Assessment Tools

평가 도구에는 다음과 같은 것들이 있다.

The three assessment methods (checklists for rating behaviors, patient questionnaires, and knowledge or attitude questions) have been incorporated into a variety of assessment tools for use in education and evaluation. Table 2 describes some of these tools, dividing them into five categories: 

• ratings of direct observation of interactions with real patients; 
• ratings of simulated encounters with standardized patients; 
• ratings of video- and audiotape interactions; 
• patient questionnaire or survey; and 
• examination of knowledge, perceptions, attitudes. 

Additional descriptions of some of these tools can be found on the ACGME Web site.3

의사소통 행동을 평가하는 목적으로 체크리스트는 가장 많이 활용되는 도구 중 하나이다. 여러 가지가 있으나 현재까지 gold standard는 없다.

For assessing communication behaviors, the checklist remains the most frequently used assessment tool. Over 25 communication and interpersonal skills rating checklists are described in the literature, but only a few have been widely used.31–37,70 Currently there is no gold standard, and standardization of instruments across clinical settings remains an important future challenge.

교육 프로그램에 평가를 포함시키기

Incorporating Assessment into Educational Programs

 

결론

Conclusions

 

Kalamazoo I Consensus Statement는 교육을 위한 task의 목록과 의사소통 역량 평가를 위한 blueprint를 만들었다. 

• The Kalamazoo I Consensus Statement provided a useful list of the tasks that define the curriculum for teaching and the blueprint for evaluation of competence in communication skills in the primary care ambulatory setting. 
• This Kalamazoo II report elaborates on competence in interpersonal skills, concluding with a summary of the assessment tools that may be used for teaching and evaluating these competencies.

이 보고서에서 제안하는 몇 가지 중요한 것들.

The Kalamazoo II proceedings presented here suggest a number of important findings. 

• 동일한 도구의 형성평가-총괄평가 반복 사용가능성 First, the same assessment tool may be used for formative evaluation and feedback during training or for summative and high-stakes evaluations for promotion, licensing, or certification. 
• 상호작용 능력을 보기 위해서는 실제 환자나 모의환자와의 접촉을 봐야 함 Second, demonstration of interactive skills demands observation and ratings of real or simulated physician–patient encounters. The raters may be actual patients, trained simulated patients, or other professionals who complete checklists or answer questions in a survey. 
• 어떤 도구를 사용하는지는 가용한 자원과 요구되는 신뢰도 타당도에 따라 다르겠지만, 최소한 의사소통과 대인관계 기술은 포준화된 체크리스트를 활용하여 잘 훈련된 평가자에 의해서 이뤄져야 함 Third, selection of the tools chosen by an educational or evaluation program will depend on the resources available and the level of reliability and validity required. At a minimum, competence in communication and interpersonal skills should be taught and evaluated by trained faculty coaches and evaluators using standardized checklists. 
• 의사-환자 관계의 핵심으로는 환자가 의사를 만난 이후 작성한 rating 또는 survey에서 얻은 환자의 관점이 중요하다. Finally, the therapeutic essence of the doctor–patient relationship should include the patient's perspective obtained either from ratings or surveys after encounters.

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Acad Med. 2004 Jun;79(6):495-507.

Assessing competence in communication and interpersonal skills: the Kalamazoo II report.

Duffy FD1, Gordon GH, Whelan G, Cole-Kelly K, Frankel R, Buffone N, Lofton S, Wallace M, Goode L, Langdon L; Participants in the American Academy on Physician and Patient's Conference on Education and Evaluation of Competence in Communication and Interpersonal Skills.

Author information

Abstract

Accreditation of residency programs and certification of physicians requires assessment of competence in communication and interpersonal skills. Residency and continuing medical education program directors seek ways to teach and evaluate these competencies. This report summarizes the methods and tools used by educators, evaluators, and researchers in the field of physician-patient communication as determined by the participants in the "Kalamazoo II" conference held in April 2002. Communication and interpersonal skills form an integrated competence with two distinct parts. Communication skills are the performance of specific tasks and behaviors such as obtaining a medical history, explaining a diagnosis and prognosis, giving therapeutic instructions, and counseling. Interpersonal skills are inherently relational and process oriented; they are the effect communication has on another person such as relieving anxiety or establishing a trusting relationship. This report reviews three methods for assessment of communication and interpersonal skills: (1) checklists of observed behaviors during interactions with real or simulated patients; (2) surveys of patients' experience in clinical interactions; and (3) examinations using oral, essay, or multiple-choice response questions. These methods are incorporated into educational programs to assess learning needs, create learning opportunities, or guide feedback for learning. The same assessment tools, when administered in a standardized way, rated by an evaluator other than the teacher, and using a predetermined passing score, become a summative evaluation. The report summarizes the experience of using these methods in a variety of educational and evaluation programs and presents an extensive bibliography of literature on the topic. Professional conversation between patients and doctors shapes diagnosis, initiates therapy, and establishes a caring relationship. The degree to which these activities are successful depends, in large part, on the communication and interpersonal skills of the physician. This report focuses on how the physician's competence in professional conversation with patients might be measured. Valid, reliable, and practical measures can guide professional formation, determine readiness for independent practice, and deepen understanding of the communication itself.

PMID:

 

15165967

 

[PubMed - indexed for MEDLINE]