의대를 다니는 동안 마음이 오히려 차가워지는가? (Academic Medicine, 2008)
Is There Hardening of the Heart During Medical School?
Bruce W. Newton, PhD, Laurie Barber, MD, James Clardy, MD, Elton Cleveland, MD, and Patricia O’Sullivan, EdD
의료 전문직업성의 중요성과 구성. 교육을 통해서 길러줘야 함에도 의과대학 기간동안 특정 부분에 대해서는 안좋은 영향만 주고 있다는 연구들이 있다. 냉소주의가 높아지고, 윤리적, 도덕적 발달이 저해된다.
Medical professionalism is essential for maintaining the integrity of the profession, and it includes demonstrating compassion, caring, and a willingness to put the concerns of patient and society above one's own. Medical education should promote the development of these professional qualities. However, studies have shown that medical school can often have a detrimental effect on certain aspects of students’ professional growth. Negative characteristics such as cynicism may increase, and ethical and moral development can be stunted.1–3
공감능력은 반드시 키워야 할 중요한 전문직으로서의 자질이다. 환자의 만족도를 높이고 치료를 더 잘 따르게 한다. 의사의 공감능력은 환자가 인지하는 치료자로서의 능력에도 영향을 준다. 진료기술이 뛰어나도 이러한 환자만족, 치료에 대한 순응, 의사의 공감능력에 대한 중요성을 모르면 환자는 '비효과적'이라고 느낄 수 있다.
Empathy is one of the most highly desirable professional traits that medical education should promote, because empathic communication skills promote patient satisfaction and adherence to treatment plans while decreasing the likelihood of malpractice suits.4,5 Patients view physicians who possess the quality of emotional empathy as being better caregivers. A physician may possess competent diagnostic skills, yet be considered by patients as “ineffective” because the physician misses the link between patient satisfaction, adherence to medical instructions, and physician empathy.
공감능력은 두 가지로 분류된다. 간접적(vicarious), 상상적(? imaginative)이다.
Sociologists and psychologists have divided the concept of empathy into two main definitions or types: vicarious and imaginative.
- Vicarious empathy 다른 사람의 감정적 경험을 인식하는 것. is “an individual's vicarious emotional response to perceived emotional experiences of others” and
- imaginative empathy 다른 사람의 입장에서 그 사람의 생각, 감정, 행동을 정확히 이해하고 예측하는 것 is “an individual's ability to imaginatively take the role of another so as to understand and accurately predict that person's thoughts, feelings and actions.6
첫 번째는 정서적 반응이다(gut reaction), 두 번째는 인지적 공감(cognitive empathy)이다.
The first definition reflects an innate emotional response, that is, a “gut reaction,” and is equivalent to the “empathic concern” described by Davis 7; the second definition refers to “cognitive” empathy and reflects a learned ability to imagine and intellectualize.7
여러 척도들이 '인지적 공감'을 측정한다. 기존의 연구에서 의과대학생의 인지적 공감은 변화가 없다고 나온 것, 올라간다고 나온 것, 내려간다고 나온 것 등 다양하다. 우리의 이전 단면연구에서 보면 의과대학기간동안 공감이 감소한 것을 확인하였다.
Many scales that measure empathy are investigating cognitive empathy of individuals to “role-play.”8 Previous data concerning medical students’ cognitive empathy are conflicting, indicating either no changes, decreases, or increases in empathy during undergraduate medical training.9–13 In our previous cross-sectional study, we observed a decline in vicarious empathy during medical school.14 There are no known longitudinal studies of vicarious empathy. In the current study, we examined the longitudinal effect of medical education on vicarious empathy.
Methods
Setting and sample.
We gathered this study's data from a single South-Central U.S. medical school: The University of Arkansas for Medical Sciences. Starting in the 1997, 1998, 1999, and 2000 academic years, the students in the graduating classes of 2001, 2002, 2003, and 2004 completed a survey at the beginning of their freshman (M1), sophomore (M2), junior (M3), and senior (M4) years. With approval from our local institutional review board in 2005, we contacted the 535 graduates and asked whether they would allow their data to be used in a research study. A total of 419 (78.3%) students agreed, 1 student refused, and 115 students did not reply.
Survey instrument.
The survey instrument was the Balanced Emotional Empathy Scale (BEES), a well-established measure of the vicarious emotional qualities of empathy that examines the emotional “primitive” level of interpersonal interactions.8,16 The BEES coefficient alpha is 0.87. The BEES consists of 30 positively or negatively worded items (15 items in each category) that measure responses to fictional situations and particular life events. Because the BEES is gender sensitive, with men scoring lower than women, the students were asked to report their gender. Using the students’ responses to the BEES, we analyzed the changes in the students’ vicarious empathy by gender across their first three years of medical school.
Specialty choice.
We classified each student's specialty choice on the basis of his or her residency match at the time of graduation. Specialty choice was divided into two categories, five core specialties (i.e., internal medicine, family medicine, pediatrics, obstetrics–gynecology, and psychiatry) and noncore specialties (all other choices, for instance, surgery, pathology, and radiology).
Timing of test administration.
Students completed the questionnaire during registration for each academic year. Therefore, the M1 classes had no medical training, providing a baseline empathy score.
Analysis of data.
Scores for each student were calculated according to BEES instructions.16 Descriptive statistics were calculated by class, gender, and choice of specialty. As stated earlier, we conducted separate analyses for men and women, because the BEES is gender specific. For each year, we conducted a two-factor repeated-measures ANOVA, using the general linear model procedure from SPSS, with the significance level set at P < .05. The between-subjects factor was specialty choice, and the within-subjects factor was time. Significant effects were followed by post hoc tests. We also performed single-sample tests of means to compare our respondents with those in the normed sample for the BEES.
Discussion
공감능력이 의학교육에 의해서 영향을 받는다는 결과. 오히려 남학생은 일반 사람들보다 더 높았다.
The results of this study suggest that student empathy is affected by medical education. Our study supports the findings of Coulehan and Williams,18 who described deleterious changes in various humanistic qualities as medical students became “immunized” against these values after their matriculation into medical school. In the freshman year, the similar M1 BEES scores for all four classes indicate that the matriculates studied were drawn from a homogenous population, and that the undergraduate education of the matriculates, predominated by basic science courses, did not decrease vicarious empathy below the established norm. Indeed, the entering male medical students had BEES scores that were significantly higher than the norm. For both the men and the women, the M1 BEES scores were not significantly different between core and noncore groups.
의과대학 1학년이 지나며 크게 감소함. 1학년을 지나면서 미디어에서 보여지는 것과 실제 모습이 차이가 있다는 것을 인지하게 되었을 것이다. 1학년들은 자신들이 애들 대접을 받는다고 느낄 것이다. 이에 대한 대응적 행동으로 냉소주의가 높아지고, VE가 감소한 것으로 본다.
For all the students studied, the significant decrease in vicarious empathy that occurred after completing the freshman year of medical school may have resulted from a high degree of student stress and anxiety caused by the students’ competitiveness and desire to overachieve on examinations. Additional stressful factors may include the media's presentation of doctors as heroes, which helps create a skewed image of the ideal physician for entering freshmen medical students. As the students progressed through their freshman year, they probably realized there is a mismatch between the media representation and reality.19 Additionally, the freshmen likely considered themselves to be in a hostile educational environment that treated them like children.20 All of these stressors induce self-preservation and coping behaviors. In our view, some of these behaviors, expressed as increased cynicism 2 and, ostensibly, decreased vicarious empathy, were used by the students to adjust to the stresses and internal conflicts associated with medical education.
2학년 기간에는 BEES 점수가 유지된다. 학생들이 적응한 것으로 보인다. 3학년 임상실습을 돌며 크게 다시 한 번 감소하는데, 이는 임상실습 첫 해에 대해 학생들이 느끼는 부담이 작용한 것으로 보인다. 특히 환자를 보는 경험이 있는 동안 크게 감소한다. 최신기술을 적용하는 것이 치료에 있어서 중요하게 강조되는 3차병원에서는 환자에 대한 공감을 형성하기가 쉽지 않다.
The sophomore year, which is an additional year of basic science courses similar to the freshman experience, maintained stable BEES scores. This may be explained by the students’ acclimating to the academic rigors of basic science courses. The junior clinical year, where all students participate in standard rotations, produced another dramatic drop in BEES scores for both the men and the women. This drop substantiates findings from the literature that suggest that the first clinical year of medical school is demanding and challenging.21 The large drop in M3 students’ vicarious empathy occurred while the students were seeing patients they had, presumably, looked forward to helping. It is interesting to note that a recent study showed that a similar drop in empathy occurred after dental students began seeing patients.22 In university tertiary care centers, empathy is hard to direct toward the challenging patients when the treatment emphasis is on technology.23 Immense cultural differences between physicians-in-training and patients may also make it more difficult to achieve adequate empathy. Physicians who are role models should work more closely with medical students to develop an empathic relationship with such patients.24 Our own findings suggest that this could be particularly important for women who enter a noncore specialty, because their drop in vicarious empathy scores more closely emulated the naturally lower empathy scores of the men than the scores of their female colleagues who selected a core specialty.
기존 연구에서 공감능력을 바탕으로 한 환자-의사 관계가 프로페셔널리즘의 중요한 측면 중 하나이며, 프로페셔널리즘과 환자-의사 관계는 병원 내 롤모델로 삼을 만한 의사들에 의해서 가장 잘 보여지게 된다고 나타난다. 다른 연구는 임상 롤모델이 계속 부족해왔음을 지적하는데, 이러한 긍정적인 롤모델이 부족한 것이 공감점수의 감소에 영향을 주었을 것이다.
Studies show that clinicians consider an empathic physician–patient relationship as one of the most important aspects of professionalism 5 and that professionalism and physician–patient interactions are best demonstrated by clinician role models at the bedside in hospitals or,25 as suggested by Benbassat and Baumal,24 in primary and chronic care clinics and/or hospice facilities. Other studies reveal a chronic lack of clinical role models,26 and perhaps a lack of positive role models could have contributed to the decline in empathy scores we observed after the completion of the first clinical year of undergraduate medical education.
복잡한 치료 요법이나 임상 롤모델의 부족함 외에도, 갓 의사가 된 사람들이나 학생들은 그들이 멘토나 롤모델에 의해서 남용(abuse)되고 있다고 느낀다는 점이 보고되고 있다. 이러한 학생에 대한 남용은 "traumatic deidealization"으로 불리곤 하는데, 이 역시 영향을 주었을 것이다. 누적되는 피로와 로테이션에 의해 환자에 대한 연속성이 떨어지는 것도 상황을 악화시켰을 수 있다.
In addition to complicated treatment regimes and a lack of clinical role models, literature shows that juniors, as student/physicians (i.e., individuals that are learning to assume an authoritative role in providing care while simultaneously being subservient to their mentors), perceive themselves as being abused by their mentor/role models.1,21,27 This student abuse has been termed “traumatic deidealization” by Kay 19 and is another factor possibly contributing to the declines in empathy. Other potential factors include fatigue and a lack of patient continuity that is exacerbated by starting a new clinical rotation every four to five weeks.
'의도한' 교육과정은 '비공식적' '숨은' 교육과정에 의해서 학생들의 기대에 못미치게 된다. 비공식 교육과정과 숨은 교육과정의 정의.
The “intended” medical curriculum, which is the formally offered and endorsed curriculum, often falls short of student expectations because of the “informal” and the “hidden” curricula.28
- The informal curriculum, as defined by Hafferty,28 “is an unscripted, predominantly ad hoc, highly interpersonal form of teaching that takes place among and between faculty and students” (e.g., in the hallway, lounge, or on-call room), whereas
- the hidden curriculum “is a set of influences that function at the level of organizational structure and culture” (e.g., advertising the amount of National Institutes of Health dollars the institution garners or espousing the need for basic science rather than humanities courses when applying to medical school).
이 두 가지가 바람직한 프로페셔널리즘을 은밀히 저하시키는 역할을 하게 되는데, 이는 학교의 정책이나 학교가 자원을 투자하는 부분과 '실제로 중요한 것'이 갈등을 일으키는 것을 학생들이 쉽게 파악하기 때문이다. 대신 비공식, 숨은 교육과정에서 강조하는 것은 의과대학의 사회적 의무와 학생의 공감 및 기타 직업전문성적 특성을 배양을 도와줄 수 있는 롤모델의 양성이어야 한다.
These latter two curricula contribute to insidious declines in desirable professional traits, because students easily recognize that campus policies and resource allocations and “what's really important to learn” often conflict with the stated institutional educational mission.1,28 Instead, the mandate that should be implicit within the informal and hidden curricula should be the societal obligation of medical schools to provide and/or train better physician role models who can aid students in overcoming losses in empathy and other professional characteristics.26
가장 흔하게 제시되는 대안은 공감적, 인문학적 교과목을 넣는 것이다. 그러나 많은 연구에서 이러한 식의 대안은 한시적이고 큰 효과가 있지 않으며, 어떤 사람들은 공감능력이 가르쳐서 기르기에 어려운 것이라고 느끼기도 한다. 전통적인 4년제 의과대학과 달리 최근 일부 6년제 학교 또는 PBL을 기반으로 하는 학교에서는 인문사회의학이나 공감에 대한 내용을 교육과정에 넣기가 더 용이하다는 점이 보고된 바 있다.
The most frequently offered solutions to ameliorate the loss of professionalism at the undergraduate medical level involve teaching students to be empathic or “humanitarian” via courses that emphasize empathic communication skills.9,12,29 Evidence suggests that in most instances the gains are modest and temporary,10,30 and some feel that empathy and compassion are increasingly difficult to teach as an individual matures.20 In contrast to traditional four-year schools, several recent studies have shown that six-year medical schools, or schools with a problem-based learning curriculum, have greater opportunities to integrate humanism and empathy into their curricula.31,32
이들 '비전통적'학교의 초기 결과보고는 긍정적이지만, 많은 사람들이 의대생이 가지고 있는 해로운 무력함(detrimental inertia)이 윤리, 도덕, 공감, 봉사지향적 태도에 의해서 가속화되고 이것이 얼마 안되는 교육을 더 한다고 극복되지 않는다고 느낀다. 일부 전공의 프로그램은 이러한 사실을 깨닫고 집중워크숍을 통해서 가르쳐보고자 하나, 그러한 교육에도 불구하고 인턴 시작 후 다섯 달만 지나면 이상주의나 공감은 감소하고 냉소주의는 올라간다는 것을 보고한 바 있다.
Despite some encouraging initial reports from several of these nontraditional schools, a large cadre feels that medical students possess a detrimental inertia, fueled by a frank decline in ethics, morals, empathy, and service-oriented attitudes, that cannot be overcome by a concurrent limited exposure to the humanities, especially when presented in an already crowded four-year curriculum.2,9,33,34 Some residency programs, aware of the reduction in humanitarian traits in medical graduates, have developed intensive workshops devoted to teaching and enhancing physician–patient interactions, yet studies show that even with such courses, idealism and empathy decrease and cynicism increases in as little as five months after the start of the intern year.35–37
We maintain that the attempted maintenance of professionalism should be part of the medical school curriculum that is combined with the reinstatement of effective bedside teaching. However, our study findings suggest that the loss of innate, vicarious empathy could make it difficult to effectively teach medical students, interns, and residents to consistently role-play empathic concern.
Acad Med. 2008 Mar;83(3):244-9. doi: 10.1097/ACM.0b013e3181637837.
Is there hardening of the heart during medical school?
Author information
- 1College of Medicine, Academic Affairs, #603, University of Arkansas for Medical Sciences, 4301 W. Markham St., Little Rock, AR 72205, USA. newtonbrucew@uams.edu
Abstract
PURPOSE:
METHOD:
RESULTS:
CONCLUSIONS:
- PMID:
- 18316868
- [PubMed - indexed for MEDLINE]