미꾸라지 한 마리가 물을 흐린다: 의사의 부적절 행위에 대한 대처 (Medical Teacher, 2010)

미꾸라지 한 마리가 물을 흐린다: 의사의 부적절 행위에 대한 대처 (Medical Teacher, 2010)

Bad apples spoil the barrel: Addressing unprofessional behaviour

WALTHER N. K. A. VAN MOOK1,2, SIMONE L. GORTER1, WILLEM S. DE GRAVE2, SCHELTUS J. VAN LUIJK3, VALERIE WASS4, JAN HARM ZWAVELING1,6, LAMBERT W. SCHUWIRTH2 & CEES P. M. VAN DER VLEUTEN2

1Maastricht University Medical Centre, The Netherlands, 2Maastricht University, The Netherlands, 3Free University of Amsterdam, The Netherlands, 4University of Manchester, UK, 5currently Head of School of Medicine, Keele University, Staffordshire, UK, 6currently member of the Board of Directors, Maxima Medical Centre, Veldhoven, The Netherlands

사회 변화와 함께 환자중심진료가 강조되고, 의학교육에서의 프로페셔널리즘 이슈가 의대생, 전공의 뿐만 아니라 의사의 모든 일생에 걸쳐서 이뤄져야 함이 강조되고 있다. 프로페셔널리즘에 대한 기존 문헌은 프로페셔널리즘을 가르치고, 배우는 것에 초점을 맞춰 왔지만, 프로페셔널하지 못한 행위와 이와 관련된 환자 안전의 문제는 기존의 관점을 대체하거나 혹은 보완하는 접근법이 될 수 있다. 본 연구에서는 의과대학생을 성격특성에 기반해서 선발하는 가능성에 대해 알아보고, 학부의학교육에서 발생하는 프로페셔널하지 못한 실수들에 대해 알아보고자 한다. 또한 이러한 졸업후의학교육과 CME에서 비프로페셔널한 실수의 정도, 감독체계와 이것을 다루는 방법 등을 알아보고자 한다.

Given the changes in society we are experiencing, the increasing focus on patient-centred care and acknowledgement that medical education including professionalism issues needs to continue not only in the residency programmes but also throughout the doctors career, is not surprising. Although most of the literature on professionalism pertains to learning and teaching professionalism issues, addressing unprofessional behaviour and related patient safety issues forms an alternative or perhaps complementary approach. This article describes the possibility of selecting applicants for a medical school based on personality characteristics, the attention to professional lapses in contemporary undergraduate training, as well as the magnitude, aetiology, surveillance and methods of dealing with reports of unprofessional behaviour in postgraduate education and CME.

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의대 학부와 레지던트 시기의 전문직답지 못한 행위가 졸업 이후에도 연결된다.

Recent landmark studies revealed that unprofessional behaviour during undergraduate and postgraduate education is associated with unprofessional behaviour and subsequent disciplinary actions by medical boards after graduation (Papadakis et al. 2004, 2005, 2008).

의사들은 CME에서도 프로페셔널리즘을 지속적으로 학습해야 한다.

Clinicians are thereafter expected to continue to learn how to be ‘better professionals’ as ‘continuous medical education’ (CME),

그러나 이것을 강요하는 것은 효과적이지도 않고, 오히려 반발만 일으킬 수도 있다.

Mandating it is however certainly ineffective (Stross & Harlan 1987), and may prove counterproductive as it may ‘be seen as personally irrelevant, or even insulting’ (Hickson et al. 2007b).

어떻게 프로페셔널리즘을 증진시킬 것인가만 생각할 것이 아니라 프로페셔널하지 못한 행동에 어떻게 대응할 것인가에 대한 우리의 생각을 새롭게 해야한다.

As Hickson et al. (2007b) stated: ‘The challenges for leaders in academic medicine are to think not only about how best to promote professionalism, but simultaneously to renew our commitment to addressing unprofessional or disruptive behaviours whenever they occur’.

Selection for medical school

의과대학은 중도탈락이 거의 없기 때문에 선발단계가 가장 중요한 평가이다. 

Since many medical schools have very low rates of attrition, the admissions procedure is argued to be the most important evaluation exercise conducted by North American schools (Eva et al. 2004; Wagoner 2006), and is increasingly used on the European continent as well.

그러나 입학 전 학업성취는 수련과정중의 성취에 대해서 매우 조금밖에 예측하지 못한다. 학부시절 수행능력의 23%, 졸업후 역량의 6%에 불과하다. 임상교육에서 훌륭한 성과를 보이는 많은 학생이 기초에서는 그렇지 못한 경우가 70%에 달한다.

However, previous academic performance proves only a limited predictor of achievement in medical training. It accounts for 23% of the variance in performance in undergraduate medical training and only 6% of that in postgraduate competency (Ferguson  et al. 2002)! Consequently, many students (70%!) who excelledin the clinical courses did not so in the basic sciences (Rhoads et al. 1974).

어떤 입학 전 행동이 프로페셔널리즘의 어떤 특정 부분과 연관되는지에 대한 컨센서스는 이루기 쉽지 않다.

it is difficult to obtain consensus as to exactly which pre-medical behaviours are associated with what specific aspects of professionalism (Wagoner 2006).

미국 의과대하의 99%가 면접을 활용하고 있지만, 이러한 유명세에도 불구하고 면접에는 두 가지 문제가 있다. 하나는 잘 보이기 위해서 꾸며진 모습만 평가한다는 점이고, 다른 하나는 맥락에 따라서 행동이 달라진다는 점이다.

A total of 99% of the US medical schools now use the interview as part of the admissions process (Puryear & Lewis 1981). In spite of its popularity, the admission interview is plagued by at least two remediable problems. First, it fails to take into account non-cognitive attributes formed for example  by personality traits (Benor et al. 1984); second, it is plagued by the problem of context specificity.

Screening for personality traits and influence of context

First, the sensitivity to detect dysfunctional tendencies due to personality characteristics is considered too low in an interview (Stern et al. 2005). These personality traits could however indicate a student’s fit with the formal curriculum. It is known that dysfunctional personality characteristics have a negative impact on the learning process, academic motivation, academic grades and course attendance

Knights et al. have extensively studied this subject (Knights & Kennedy 2006, 2007). They report that dysfunctional tendencies are not uncommon in a survey among first-year medical students.

Another example of another self-reporting method to specifically assess interpersonal problems is the Hogan Development Survey

Furthermore, the interview is plagued by the problem of context specificity, the fact that many of our cognitive ‘skills’ are highly dependent on context (Eva et al. 1998). A person’s performance is commonly less determined by ‘trait’, the personality characteristics, than by the ‘state’, e.g. the context within which the performance is elicited (Eva et al. 2004). To overcome this problem, a multiple mini-interview protocol consisting of a series of short OSCE-style stations was developed.

한 사람의 수행능력은 그 사람의 내재적 '특질'이 아니라 그 사람이 처한 '상태'에 따라서 달라지는 부분이 더 크다. 이러한 문제를 극복하고자 MMI가 개발되었다. MMI에서도 연구결과에 따르면 지원자-스테이션간 상호작용에 따른 영향이 지원자 단독에 의한 영향보다 컸다. 

Indeed, the variance component attributable to candidate–station interaction was greater than that attributable to candidate, supporting the hypothesis that the context specificity reduces the validity of traditional interviews (Eva et al. 2004).

Attention to professional lapses in undergraduate training

프로페셔널하지 못한 행동을 잡아내는 방법으로 두 가지가 있다.

Different approaches to signalling unprofessional behaviour can be adopted (van Mook et al. 2009c). 

The first is a system in which faculty members reflect on students’ professional performance over a longer period of close observations and guidance. 

The second approach seems especially appropriate for the hectic clinical environment where the number of the faculty have brief interactions with students. The evaluation in that context more resembles ‘one-time snapshots’. 

이러한 critical incident 방식은 'extreme'에 있는 학생에게 효과적이다.

These so-called ‘critical incidents’ document a specific sentinel event in detail and ‘particularly useful for the students at the extremes of performance’.

예시들도 있다.

Although several, mainly US, examples of critical incidents reporting systems can be found in the literature (Papadakis et al. 1999, 2001; van Mook et al. 2009c), examples from the European continent are so far lacking.

맥락에 따라 봐야 한다.

When attempting to establish whether a certain behaviour is acceptable or not, the behaviour should be looked at within its appropriate context, the environment in which it occurred (Fochtmann 2006; Sullivan & Arnold 2009).

이러한 부적절한 행동들이 완전히 굳어지기 이전에 조기 발견하는 것이 매우 중요하다. 

Early lapse identification is critical to facilitate institution of such strategies before such behaviour becomes refractory to change (Sullivan & Arnold 2009)

기록하는 것이 중요하다.

It is needless to say that candid documentation of every incident, the remediation strategy and the response is required. All reports should be confidentially handled, and complainants should receive follow-up of review and resulting actions (Sullivan & Arnold 2009).

여러번 지적받은 학생이 프로페셔널한 발전이 더디고, 발견된 문제의 책임을 자신의 것으로 받아들이지 못하며 오히려 불공정하고 부정확하다며 평가자를 비난한다.

Comparing to reports by Papadakis et al., we have the strong impression that students who receive multiple critical incident reports have significant deficits in professional development, and it frequently encountered that they do not accept responsibility for the problems identified, and accuse the evaluators of unfairness and inaccuracy (Papadakis & Loeser 2006).

Unprofessional behaviour in postgraduate education and CME

-문제의 정도 Magnitude of the problem

Estimates of the magnitude of the problem of impaired physicians at some point in their careers vary from 3–5% to approximately 15% (Boisaubin & Levine 2001; Leape & Fromson 2006).

-문제의 종류 Aetiologies of unprofessional behaviour

The aetiologies of unprofessional behaviour include at least the following drivers: substance abuse, psychological issues, inappropriate handling of narcissism, perfectionism and/or selfishness, spill over of chronic or acute family/home problems, poorly controlled anger due to different causes (e.g. poor clinical/administrative support), rewarding of unprofessional behaviour since it yields desired results, and clinical and administrative inertia (no early feedback provided), and similar behaviours are observed in the environment (Leape & Fromson 2006; Hickson et al. 2007b).

-감시와 보고 시스템 Surveillance and reporting

The eyes and ears of patients, visitors and healthcare team members are considered to be the most effective surveillance tools for detecting unprofessional behaviour.

그러나 종종 이러한 불평불만은 문제를 일으킨 주치의나 담당 부서가 누구인지를 찾는것으로 귀결되곤 한다.

Nevertheless, the complaints are then aggregated to identify attendings, physicians or units that demonstrate disproportionate shares of complaints (Pichert et al. 1998; Hickson et al. 2002, 2007a, 2007b).

환자와 동료에 의한 감시만으로는 불충분하며 intervention이 늘 필요하다.

Surveillance by patients and healthcare team members alone will not suffice. Intervention is always necessary, even in the case of single incidents.

-보고 결과에 대한 대응 Dealing with the reports

When unprofessional behaviour by a resident is observed, the programme director is responsible for addressing the problem. For practicing physicians, the department’s chair, a hospital’s review committee, state or national licensing board, or judicial tribunal is responsible (Sullivan & Arnold 2009). So far however, few organizations have formal programmes to identify problem doctors (Leape & Fromson 2006; Hickson et al. 2007b), and management of problems, once identified, has frequently been haphazard, ad hoc, informal and reactive (Leape & Fromson 2006).

-대응의 규격화 Formalising the response

To optimize dealing with professional lapses and unprofessional behaviour, implementing a routine, formal, pro-active system of monitoring and remediation has been proposed (Leape & Fromson 2006).

Costs and potential benefits

모든 학년의 모든 학생을 대상으로 이러한 평가시스템을 도입하는 것에 대한 비용은 엄청나지만 피해갈 수는 없다.

When implementing an assessment system for professional behaviour for all students in all years of medical school, the accompanying administrative burden (and related cost) is enormous, but unavoidable (van Luijk et al. 2000; Fochtmann

실제로 문제를 일으킨 사람을 대상으로 대처해나가는 것은 비용을 절감하는 방법이면서도, 구성원의 만족을 높이고 대학과 병원의 평판을 높이는 길이기도 하다.

Dealing with those displaying unprofessional behaviour potentially contributes to ultimately cost-saving benefits including improved staff satisfaction and retention, improved reputation of the university centre and their leaders, institutional culture building and role modelling, improved patient safety, and reduced liability exposure (Hickson et al. 2007b).

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Med Teach. 2010;32(11):891-8. doi: 10.3109/0142159X.2010.497823.

Bad apples spoil the barrel: Addressing unprofessional behaviour.

van Mook WN1, Gorter SL, De Grave WS, van Luijk SJ, Wass V, Zwaveling JH, Schuwirth LW, Van Der Vleuten CP.

Author information

• 1Department of Intensive Care, Maastricht University Medical Centre, P. Debeijelaan 25, 6202 AZ Maastricht, The Netherlands. W.van.mook@mumc.nl

Abstract

Given the changes in society we are experiencing, the increasing focus on patient-centred care and acknowledgement that medical education including professionalism issues needs to continue not only in the residency programmes but also throughout the doctors career, is not surprising. Although most of the literature on professionalism pertains to learning and teaching professionalism issues, addressing unprofessional behaviour and related patient safety issues forms an alternative or perhaps complementary approach. This article describes the possibility of selecting applicants for a medical school based on personality characteristics, the attention to professional lapses in contemporary undergraduate training, as well as the magnitude, aetiology, surveillance and methods of dealing with reports of unprofessional behaviour in postgraduate education and CME.

PMID:

 

21039099

 

[PubMed - indexed for MEDLINE]