턴 순환(rotational)식 교육에 대한 재고 (Medical Education, 2011)

턴 순환(rotational)식 교육에 대한 재고

The rotational approach to medical education: time to confront our assumptions?

Eric Holmboe,1 Shiphra Ginsburg2 & Elizabeth Bernabeo1

CONTEXT:

학부의학교육과 졸업후의학교육 과정에서 학습자들은 수 차례의 이행과도기(transition)를 겪게 되는데, 이는 주기적으로 뿐만 아니라 단 하루 안에도 발생하기도 한다. 사전에 스케줄이 결정되어 짧은 수련이 반복되는 방식으로 진행되는 임상실습은 Abraham Flexner의 보고서에 기초한 것으로, 이러한 방식의 장점은 최적의 수련기간과 구조는 어떠해야 하며, 한 과에서 다른 과로의 이행(transition)이 어떠해야 하는지에 대한 근거가 부재한 상태로 오랜 기간 활용되어왔다. 

Trainees in undergraduate and postgraduate medical education engage in multiple transitions as part of the educational process, including many transitions that occur on both periodic and daily bases within medical education programmes. The clinical rotation, based on either a medical discipline or clinical care setting and occurring over a predetermined, short period of time, is a deeply entrenched educational approach with its roots in Abraham Flexner's seminal report. Many assumptions about the presumed benefits of clinical rotations have become pervasive despite a lack of empirical evidence on their optimal timing and structure, and on how transitions between clinical rotations should occur.

METHODS:

사회학적, 학습이론적, 질과 안전 향상 측면에서 보고자 함.

In this paper, we examine the issue of rotational transitions from the three perspectives of sociology, learning theory, and the improvement of quality and safety.

RESULTS:

사회적 관점에서 여러 전문직간 관계와 전문직으로서의 성장에 더 많은 관심을 둘 필요가 있다. 학습이론적 관점에서 인지과학과 교수이론에서 제시하는 방식과 현재 하고 있는 방식 사이에 어떤 차이가 있는가를 확인할 수 있었으며, 질과 안전의 측면에서는 학습자를 임상 소생태계(clinical microsystem)에서 보다 의미있는 참여자로 참여시킬 필요가 있다.

Discussion from the sociological perspective addresses the need for much greater attention to interprofessional relationships and professional development, whereas that from the learning theory perspective examines the gap between what is known from pedagogical and cognitive science and what is currently practised (learning theory). Discussion from the perspective of improving quality and safety refers to the critical need to embed trainees in functional clinical microsystems as meaningful participants.

CONCLUSIONS:

이행과도기(transition)가 학습자/교수/기타보건의료직/환자에게 미치는 영향을 연구할 필요가 있다.

Research is urgently needed on the effects of transitions on trainees, faculty staff, non-doctor health care providers and patients in order to optimise future competency-based training models and confirm or refute current assumptions.

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• However, the Flexnerian revolution also led to greater emphasis on structure and process in training, including curricula grounded in the ‘scientific basis of medical practice and clinical experience’, and inspired current medical education as a teacher-centred system in which trainees advance as a function of ‘dwell’ time, simply based on the amount of time spent in a program.1,2 

• 과거에는 의대만 다녀도 충분했음. At the time of the Flexner report, the completion of medical school was considered sufficient to prepare the vast majority of individuals to practise medicine.

• 전 세계적으로 비슷함. The situation is similar throughout the rest of the world. In Canada, for example, the length of rotations varies substantially among specialties, but most PGME rotations in Canada last 4–8 weeks8,9  

• OBME로의 이행이 어려운 이유 However, the transformation to outcomes-based medical education is causing significant tension within the medical education community and often makes agonisingly slow progress.13 One likely cause of this tension and slow progress may be that educators are trying to insert competency-based assessments and curricula into a system that is clearly designed to emphasise structure and process, including the use of multiple clinical rotations, over outcomes.

• 1년에 걸친 턴과 At the first level are the rotations trainees must complete.
• 하루 내에서도 바뀌는 턴 At the second level are the daily transitions trainees experience while on a rotation

• 교수들도 한 unit을 기준으로는 잠시 머무는 사람일 뿐 Moreover, like trainees, many faculty staff are transient members of the clinical units in which they supervise trainees and oversee patient care.

간호사와 기타 보건의료인력은 수련의/교수/환자와 환자 가족에게 있어서 중요한 '연속성'의 요소이다. The main difference is that nurses and ancillary staff are the stable members of the clinical unit. They serve as vital threads of continuity, not only for trainees and faculty members, but, perhaps more importantly, also for patients and their families, but little is known about how the disruption caused by moving trainees and faculty in and out of the clinical unit affects these vital health care workers.

• 현재의 가설은 아래와 같음
• 1 frequent rotations allow for greater diversity and breadth of exposure to different disciplines and more opportunities to learn in medical school, and, in postgraduate training, more concentrated focus on subspecialty areas as a method to develop expertise; 
• 2 frequent rotations effectively teach residents how to adapt to and cope with multiple practice styles, varying expectations and stress, all of which are skills that will be necessary in their future practice, and 
• 3 frequent rotations promote greater trainee independence in action by forcing them to adapt and learn on their own.

• 이러한 가정들이 인증평가 기준에 반영되어 있음. These assumptions have been codified and reinforced by accreditation and certification policies in several countries, most notably the USA and Canada, 8,9,24,25 the development of which was spurned by the Flexner report.26

THE SOCIOLOGICAL PERSPECTIVE

• 수련의 사회학적 의의 Sociologists conceive of medical training as a process by which new values and behaviours are inculcated, appropriate to ‘membership’ in the field of medicine

• Switching medical students and residents between clinical services every 2–4 weeks may impede or delay adequate socialisation, resulting in specific behaviours and patterns that may be counterproductive to both professional development and patient care

• To begin, there is evidence suggesting that the ‘hidden curriculum’ and the mixed messages learners frequently experience during clinical rotations may erode the humanistic traits essential to the delivery of high-quality care.41

• Further, frequent transitions may marginalise trainees’ relationships with patients.

• Although meaningful relationships with patients are unquestionably important, so are relationships with others on the health care team.47–49 Too often the definition of ‘team’ for a trainee is the trainee him- or herself, the other medical trainees on the rotation (students, interns, etc.) and the faculty attending doctor, a definition that fails to acknowledge other individuals caring for the patient.

• '자율성'에 대한 재정의가 필요함 In essence, professional autonomy should be granted and re-conceptualised as ‘relational autonomy’.51 Relational autonomy recognises that human agents are interconnected and interdependent, meaning autonomy is socially constructed and that action is:
• ‘…dependent upon particular social relationships and the power structures in which we are embedded. Autonomy requires more than mere freedom from interference; it requires that one’s relationships with particular individuals and institutions be constituted in such a way as to give one genuine opportunities for choice.’51

THE LEARNING THEORY PERSPECTIVE

• There is a mismatch between the broad range of learning theories offered in the wider education literature and the relatively narrow range of theories privileged in the medical education literature.54

• Faculty should be working alongside trainees on a daily basis to provide real-time evaluation and feedback. Ericsson’s61,62 seminal work highlights the importance of coaching, role-modelling and mentoring as part of the development of expertise.

• Yet, it is hard to imagine how moving trainees and faculty (the presumed coaches) around every 2–4 weeks facilitates high-quality assessment and feedback. 

• This situation makes it very difficult for the trainee to develop a meaningful relationship with the faculty teacher, and leads to, at best, superficial assessment and feedback.

• 다른 교수에게 피드백에 관해 정보를 잘 안주게 됨. 새 교수는 바닥부터 시작함. Compounding this situation is the reluctance to feed forward information about trainees from one faculty member to the incoming member because of fears, bias or prejudice around grades.63–65 The net result is that the new faculty member must start from scratch (if at all) to determine where the trainee is developmentally. 

• 수련의들은 impostorism, 즉 그 때만 잘 넘기자는 식의 태도를 가지게 됨 Lastly, we know that trainees’ abilities to self-assess and self-supervise are inadequate and inaccurate (as they are in all professionals), especially among the least knowledgeable and skilled.68–70 Trainees are also at risk for feelings of impostorism,71 characterised by an inability to internalise a sense of competence or skill despite concrete evidence of their abilities.72

• However, as trainees are repeatedly forced to adapt to new clinical rotations, expectations, responsibilities and pressures, it is possible that a subset fail to realise or reach their potential as they simply do what they need to in order to ‘survive’ and endure each transition.

• 물론 평가이론에 근거하자면 다수의의 평가자가 참여하면 '공정성'은 향상될 수도 있음 In fairness, some educators might argue that frequent transitions improve equitability in evaluation by increasing the sample of faculty and others who evaluate and judge the trainee. This is certainly consistent with psychometric principles: reliability is usually better with higher numbers of evaluators.74

THE QUALITY AND PATIENT SAFETY PERSPECTIVE

• Unfortunately, substantial evidence exists that trainees too often must learn and work in dysfunctional microsystems.32,88

• 좋은 소생태계란..As Batalden and colleagues pointed out, successful microsystems are characterised in part by strong interdependence between members, continuous quality improvement and the generation of performance results.87

• These challenges are even more acute in ambulatory training, in which trainees in a number of specialties may rotate in and out of a clinic to see patients for perhaps half a day per week, or may rotate between multiple clinics during an ambulatory block or posting.

• However, as noted in several recent reviews, trainees are seldom active participants on quality improvement teams or projects, and the rotational nature of training is a major contributor to this current state of affairs.93,94

• Trainees are also a valuable source of information about what doesn’t work and can provide valuable insight into how to improve work processes and safety.97,98

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Med Educ. 2011 Jan;45(1):69-80. doi: 10.1111/j.1365-2923.2010.03847.x.

The rotational approach to medical education: time to confront our assumptions?

Holmboe E1, Ginsburg S, Bernabeo E.

Author information

• 1American Board of Internal Medicine, Philadelphia, Pennsylvania 19106, USA. eholmboe@abim.org

Abstract

CONTEXT:

Trainees in undergraduate and postgraduate medical education engage in multiple transitions as part of the educational process, including many transitions that occur on both periodic and daily bases within medical education programmes. The clinical rotation, based on either amedical discipline or clinical care setting and occurring over a predetermined, short period of time, is a deeply entrenched educational approach with its roots in Abraham Flexner's seminal report. Many assumptions about the presumed benefits of clinical rotations have become pervasive despite a lack of empirical evidence on their optimal timing and structure, and on how transitions between clinical rotations should occur.

METHODS:

In this paper, we examine the issue of rotational transitions from the three perspectives of sociology, learning theory, and the improvement of quality and safety.

RESULTS:

Discussion from the sociological perspective addresses the need for much greater attention to interprofessional relationships and professional development, whereas that from the learning theory perspective examines the gap between what is known from pedagogical and cognitive science and what is currently practised (learning theory). Discussion from the perspective of improving quality and safety refers to the critical need to embed trainees in functional clinical microsystems as meaningful participants.

CONCLUSIONS:

Research is urgently needed on the effects of transitions on trainees, faculty staff, non-doctor health care providers and patients in order to optimise future competency-based training models and confirm or refute current assumptions.

© Blackwell Publishing Ltd 2010.

Comment in

• Developmental aspects of medical competency and training: issues of curriculum design. [Med Educ. 2011]

PMID:

 

21155870

 

[PubMed - indexed for MEDLINE]