의사들의 이주: 문화적 이행기에 있는 의사들의 전문직업성 (Med Teach, 2015)

의사들의 이주: 문화적 이행기에 있는 의사들의 전문직업성 (Med Teach, 2015)

‘‘Doctors on the move’’: Exploring professionalism in the light of cultural transitions

JUDY MCKIMM1 & TIM WILKINSON2

1Swansea University, UK, 2Otago University, New Zealand

현대 의학은 글로벌하다. 우리는 전 세계의 의사로부터 이익을 얻고, 다른 국가들은 다른 곳에서 양성된 의사로부터 혜택을 본다.

Modern medicine is global: we benefit from the skills ofdoctors from around the world and other nations benefit from doctors trained elsewhere (General Medical Council 2014).

McLean은 global health practitioner 양성에 대해서 다음과 같이 말했다.

McLean suggest that ‘

‘institutions should...be producing medical graduates who can think globally but act locally to deliver appropriate healthcare and adapt to the changing needs of communities and populations, irrespective of where they practice medicine – a global health practitioner’’ (2011,)

이러한 문화의식은 전문직으로서 갖춰야 할 것이지만, 많은 의사들은 여기에 어려움을 겪고 있으며, 특히 다른 국가로 이주해갈 때 그러하다.

We suggest that such cultural awareness is part of being a professional, yet it is an area in which many doctors struggle, particularly when they move to countries with very different cultures.

'프로페셔널리즘'이라는 개념 자체도 문화적으로 구성되고 정의된다. 또한 시간에 따라 변화며 개념과 정의도 보건의료인 또는 대중(public)에 따라 다르다. 프로페셔널리즘이 무엇인가에 대한 전 세계적인 단 하나의 답은 없으며 전문직과 사회 간에 지속적으로 중재되는 계약이라고 할 수 있다. NIH는 문화를 다음과 같이 정의한다.

The concept of ‘‘professionalism’’ is itself culturally constructed and defined, it changes over time and concepts and definitions vary amongst health practitioners and the public (Wilkinson et al. 2012). There is no ‘‘universal truth’’ about what professionalism is – it is a constantly mediated contract between the profession and society (Cruess & Cruess 2010). The US National Institute for Health (NIH) describes culture as 

the combination of a body of knowledge, a body of belief and a body of behavior. ...personal identification, language, thoughts, communications, actions, customs, beliefs, values, and institutions that are often specific to ethnic, racial, religious, geographic, or social groups. ...these elements influence beliefs and belief systems surrounding health, healing, illness, wellness, disease, and delivery of health services’ (www.nih.gov/clearcommunication/ culturalcompetency.htm).

한 나라의 문화와 무관하게 모든 의사들은 '일반인'에서 '전문직'으로 문화적 이주를 겪게 된다. 의료전문직의 가치와 규범을 배우며, 학생과 일반 사회 구성원으로서의 가치는 내려놓게 된다. 많은 학생들이 이러한 변화를 겪느라 고생하지만, 특히 IMG는 Professional socialization과 Acculturation이라는 두 가지 형태의 이주를 동시에 겪게 된다. 

Regardless of national culture, all doctors make the culturalshift from layperson to professional – ‘‘taking on’’ the valuesand norms of the medical profession and leaving behind someof their values as students and general members of society.Many students struggle with this transition but IMGs have tomake two major ‘‘shifts’’ in terms of (1) professional socializa-tion and (2) acculturation, which embody an interlinkedrecalibration of their social and professional identities

학생과 의사는 자신의 문화와 다른 문화에서 온 사람들과 함께 일하며 배워야 한다. 의사들이 환자의 가치와 규범을 의사결정에 포함시키고자 하는 동시에, 의사와 환자가 서로 다른 문화적 신념과 이해를 가지고 있을 때 하나의 레벨이 더 추가되며 이는 '문화적 역량'이란 것이다. 

Students and doctors have also to learn to work with people from cultures different from their own. Whilst doctors aspire to include patients’ values and norms into decision- making, when the patient and doctor have different cultural beliefs and understandings, an additional level is added to consultations – these are components of ‘‘cultural compe- tence’’, represented in Figure 1 by the double arrow.

의사로서 성장하고 정체성을 만들어가는 과정에서 여러 부분에서 문화적 이주가 나타나며, '비전문적인' 행위 문제를 야기할 수 있다.

Various points in cultural transitions occur where a doctor’s development and identity formation may become problematic and lead to ‘‘unprofessional’’ behaviors: 

(1) The transition to professional socialization or identity formation may be arrested. 의사처럼 행동해야 하는 것

For example, when students act like students but should be acting like doctors – being late for a lecture may have been acceptable but being late for a ward round is not (Case Example 1). Occasionally, students act like doctors but should be acting more like students, e.g. when a student is over-confident and tries to perform a procedure outside their scope of competence; 

(2) The acculturation may become problematic. 본국의 문화에서 새 문화로의 적응의 어려움

IMGs or elective students may act in ways appropriate to the norms and expectations of their home culture but inappropriate in the new culture e.g. attitudes to alcohol, appearance, or condescending attitudes to lack of avail- ability of expensive investigations or medications (Case Example 2); 

(3) A student or doctor imposes their own cultural values and beliefs on a patient/service user from a different culture, 자신의 문화적 가치를 강요함

e.g. how women are regarded or the role a patient may wish to play in negotiating treatment decisions (Case Example 3).

전문직의 사회화는, "되어가고, 되고, 소속되고"

Professional socialization – ‘‘Becoming, being and belonging’’

사회적, 전문적 정체성

Social and professional identity

전문가적 정체성은 더 넓은 범위에서의 사회적 정체성이며, 개인의 고국과 문화적 배경이 어딘가에 따라 달라진다. 따라서 모든 의사는 사회적 정체성에 의해서 영향을 받은 전문가적 정체성을 지니게 되며 "나(사회 속 개인)"이 "우리(의사 집단)"이 되고, "다른 사람들"이 보다 명확히 규정되고, 집단의 정체성 유지에 중요한 역할을 한다. 의사들은 그들이 간호사가 아님을 알며, 간호사는 그들이 물리치료사가 아님을 안다.

Professional identity is part of a widersocial identity, which varies depending on the person’scountry of origin and cultural background (ethnicity, religion,etc). So every doctor has a professional identity which isinfluenced and constructed by a social identity. Doctors arepart of a group, and as ‘‘me’’ (individual social self) becomes‘‘us’’ (doctor group self), so do ‘‘the others’’ become moredefined and important in maintaining the group identity.Doctors know they are not nurses, nurses know they are notphysiotherapists,

그러나 여기서도 문화가 등장한다. 간호사와 의사의 관계 어떤 문화에서는 위계적이지만 어떤 문화에서는 평등하다.

Yet even here, there are cultural overlays, e.g.relationships between doctors and nurses can be hierarchicalin some cultures and egalitarian in others.

전문직으로서, 그리고 사회안에서 보건전문직의 역할은 전통적으로 잘 정해져 있다. 이것은 기본적으로 의사들간, 의사와 다른 보건의료인간, 의사와 대중간의 관계에 영향을 준다. 의사가 어떻게 행동하고, 바라보고, 말해야 하는가에 대한 기대와 윤곽과 프로토타입은 사회적으로 구성되며, 보건의료에 관여되어있는 모든 사람에 의해서 형성된다. 의사의 행동과 기질은 그러한 윤곽에 의해서 평가되며, 개개인이 의사에 대해 갖는 기대에 큰 영향을 준다. 이것은 왜 어떤 의사들이 기술이나 전문성이 아니라 성별, 성적 정체성, 장애, 연령, 인종을 이유로 받아들여지지 않는가에 대한 이해에 도움을 준다. 현실적인 의미에서, 이것은 왜 어떤 의사들은 의사가 어떻게 보이고 행동해야 하는가에 대한 깊이 뿌리박힌 (그러나 잘 설명되지 않는) 믿음을 극복하기 위해서 더 열심히 노력해야 하는가를 의미한다. 역사적으로 그리고 지금까지도 의사에 대한 프로토타입은 의사, 유색인종, 소수민족, 장애인 등을 배제하고 있다.

Roles in the health professions are well-established along traditional lines both professionally and socially (Mannion et al. 2015). This fundamentally informs and influences relationships between different doctors, relationships between doctors and other health professionals and between doctors and the public. Expectations, schemata and prototypes of how doctors should behave, look and speak are socially con- structed and mediated by all those engaging in healthcare. Attributes or behaviors of doctors are measured against such schemata and are highly influential in shaping individuals’ expectations of doctors. They help to explain why some doctors may not be accepted if they do not fit prototypes based, not on skill or expertise, but on general attributes such as gender, sexuality, disability, age or race (Mannion et al. 2015). In practical terms, this means that some doctors may have to work harder to overcome deeply held (but not always articulated) beliefs about what doctors should look like and behave. Historically and to the present day, doctor prototypes have served to exclude women, non-whites, ethnic minorities and doctors with disabilities.

전문가 되기

Becoming a professional

의사라는 전문직에 들어서는 모든 사람은 전문직적 사회화 과정을 거친다.

All those entering the profession of medicine go through professional socialization.

일단 개인이 관련된 규준, 가치, 행동을 습득하고 따를 수 있게 되면 그들은 그 문화에서 수용가능한 일원이 되며, 어떤 요구되는 행동과 역할을 적절히 수행할 권리도 부여받는다. 여기에는 그들과 다른 전문직, 환자, 가족 사이의 경계를 인식하는 것도 포함되며, 이 유동성을 다룰 수 있어야 한다.

Once an individual has acquired and/or learned to display the relevant norms, values and behaviors, they become an accepted member of that culture and are accorded the rights to perform the required activities and role appropriately. They are also aware of the boundaries between themselves, other profes- sionals, patients and families and can negotiate these fluidly.

다른 하위문화를 바라보는 다른 방식은 "종족과 영토"라는 개념에 따르는 것이다. 의학의 여러 전문과는 각각 "존재와 행동"에 대한 다양한 형태를 보인다. 한 종족에 속한다는 것은 매우 안정적인 것으로서, 어딘가 속해 있다는 것을 아는 것은 매우 유용하다. 그리고 어디엔가 속해 있다는 것은 '영토'의 문제와 따라오게 되는데, 여기에는 물리적 공간 뿐 아니라 지식/시설/시간과 사람에 대한 통제에 대한 것을 포함하기에 종족간 전쟁(tribal warfare)를 유발하기도 한다. 이러한 전쟁은 환자에게 악영향을 줄 수 있는 의사소통의 장애, 전문직과 전문과간의 갈등 등을 특징으로 한다. 또한 환자를 "타자화(othering)"하기도 하는데, 환자를 마치 의사와 다른 '종족'에서 온 것처럼 바라봄으로써 비인간적으로, 열등하게 생각할 위험이 있다.

Another way of thinking about the different subcultures that inhabit healthcare and medical practice is in terms of ‘‘tribes and territories’’ (Becher & Trowler 2001). Medical specialities, different health and social care professions, and healthcare managers all have distinguishing features and ways of ‘‘being and behaving’’. Belonging to a tribe can feel very comforting: it is good to know that you belong, that you are a surgeon, a gastroenterologist, a medical educator or a family medicine doctor. And when belonging comes with a territory, which may be physical space (e.g. an operating theatre or a clinic), or a body of knowledge, equipment, control over time or people then this can give some tribes more power or status than others and lead to ‘‘tribal warfare’’. Such ‘‘warfare’’ may be characterised by miscommunication, or conflict between professions and specialties which may adversely affect patient care. It can also contribute to the ‘‘othering’’ of patients – where patients are regarded as coming from a different ‘‘tribe’’ from doctors and therefore risk being regarded more imper- sonally or as inferior (Figure 2).

문화간 차이는 동양과 서양에서도 찾아볼 수 있다.

Cross-cultural differences may be identified by some aspects of Western medicine which differ from those of the East. 

중국의 도덕성 For example, Ho et al.’s (2014) study of a Chinese medical school found a strong emphasis on the professional attributes of morality (as exemplified by adherence to one’s principles, public-spirited and humanistic Confucian values). 

서양의 의사소통 Contrast to this is Bensing et al.’s findings on (Western) doctor patient communication, which indicated a shift ‘‘towards a more business-like, task-oriented GP (general practitioner) – patient communication pattern, reflecting the recent emphasis on evidence- based medicine and protocolized care (raising) concerns ...about the effectiveness of modern medicine in helping patients voice their worries’’ (Bensing et al. 2006). 

동양에서 서양, 서양에서 동양으로 이주하는 의사는 서로 다른 전문가적 가치와 의학에 대한 철학적 접근법의 차이로 고생할 수 있다. 이는 임종에 관한 문제에서 특히 더 두드러질 수도 있다.

Doctors moving from East to West, and vice versa, may well struggle with such different professional values and philo- sophical approaches to medicine as they play out in the clinic or consultation. This is further highlighted with end of life issues where cultural differences can become more pro- nounced and poignant. 

또 다른 관점에서 누군가가 한 종족(우리 집단)에 속할 때, '우리 집단'이 효과적으로 작동하려면 반드시 '다른 집단'이 있어야 한다. Tee 등은 '집단'이란 것이 비슷하지 않은 사람들끼리 등을 돌리게 만들기도 하지만, '다른 집단'에 대항할 때 지도자를 더 지지해주는 기능도 한다라고 주장하였다.

From another perspective, belonging to a group (or tribe) means that you belong to an ‘‘in-group’’ and for an in-group to function effectively, there must be an ‘‘out-group’’. In light of the apparent importance of social and professional shared identity within teams, the concepts of ‘‘in-groups’’ and ‘‘out- groups’’ in the clinical environment is therefore relevant. Tee et al. (2013) assert that, not only do groups turn against members who are perceived as dissimilar but also that a group will support a leader more strongly when they explicitly oppose an out-group.

집단 정체성은 의사와 다른 보건의료직의 구분을 강화하는 것이기도 하지만 의사(그리고 IMG)는 동질적인 집단이 아니며, 이 커다란 집단 안에 우리 집단과 다른 집단의 여러 층위가 있다. 이러한 집단이 존재하는 것의 위험성은 '다른 집단'을 그저 다른 사람들이라고 보는 것이 아니라 개개인이 아닌 집단을 엮어서 무언가에 실패했을 때 비난의 대상으로 삼는다는 것이다. 이러한 '고정관념의 위헙'이라는 개념은 어떻게 IMG가 '우리 집단'에 대한 위협으로 인식되는 것을 악화시킨다.

Group identity is reinforced by the clinical expertise that sets doctors apart from other health professionals, but doctors (and IMGs) are not a homogenous group and within these larger groupings lay further layers of in-groups and out-groups. A danger of such groups’ existence is that out-groups may be seen not only as very different, but may even be blamed for service failings or stereotyped instead of being treated as individuals. The concept of ‘‘stereotype threat’’ may also exacerbate how IMGs (and others who seem different) can be seen as threatening to the in-group.

Cruess와 Cruess는 프로페셔널리즘을 정의하는 방법이 지역, 문화, 전문직의 맥락과 밀접히 연결되어야 한다고 주장했다. 개인보다는 집단에 초점을 맞추는 비-서양의 문화에서 프로페셔널리즘은 더 많은 보건의료인을 포함하게 된다. 

Cruess & Cruess (2010) suggest that the way professional- ism is defined should be tied closely to local, cultural and professional contexts. Cultural differences exist between Western models and other cultures which may focus less on the individual than the collective and which often include a wider range of health workers, such as traditional healers or birth attendants and spiritual aspects. 

Fig 3을 보면, 의사의 전문직적 사회적 정체성이 비교정 명확했던 본국에서 생소한 다른 국가로 이주할 때 두 개의 정체성 변화가 일어나고 정체성 갈등을 겪게 된다. IMG는 여기서 그 사회의 '외부인'이 될 뿐만 아니라, 다른 부류의 의사로서도 적응해야 한다. 이는 즉 IMG 의사들이 의료전문직 사이에서 '우리'가 아니라 '그들'로 인식된다는 것이다.

In Figure 3, we can see that in moving from their ‘‘home’’ country where a doctor’s professional and social identity is relatively clear (as defined by professional standards and guidance, expectations from and that patients and the public the profession itself in country) a double identity shift has to occur which can lead to identity conflict. Not only does the IMG have to adjust to being an ‘‘outsider’’ ’ or ‘‘incomer’’ to society (they may need a visa, work permit etc), they also have to adjust to been seen as a different sort of doctor, e.g. an IMG. This means that they are not necessarily part of the ‘‘us’’ of the medical profession, and may even be seen as part of ‘‘the other’’.

지도자와 다른 사람간의 '권력 거리'는 문화에 따라서 다르며, 환자-의사 관계도 마찬가지이다. 이것을 이해한다는 것은 새로운 행동 양식을 배우는 것 뿐만 아니라 문화적 규범과 가치에 깊게 새겨진 행동을 unlearn하는 것도 포함한다.

Nuances such as the ‘‘power-distance’’ relationship (Hofstede 1983) between leaders and others (i.e. the way in which people can get near to or communicate closely with leaders) vary between cultures as does the way in which the doctor- patient relationship is defined (e.g. as paternalistic, protective, advocatory, empowering or partnership). Understanding this means that individuals may not only have to learn newways of behaving and working but may also have to unlearn behaviors (such as deference) based on deeply held cultural norms and values.

Ho 등은 윤리적 딜레마에 응답하는 학생들을 통한 비교연구에서 동양과 서양의 문화적 차이를 밝혔다. 아라비안 국가의 Four gates. 

Ho et al. (2012) comparative study of medical students from Taiwan and Canada responding to ethical dilemmas also demonstrates cultural differences between East and West. The Taiwanese students drew from their cultural practices around social relationships and protection of the patient and were highly respectful of their seniors and cultural norms. Many interventions that aim to develop ‘‘cultural awareness’’ focus on race and ethnicity. Although this is important, taking a broader view of what culture entails avoids possible stereo- typing and includes taking account of gender, sexual orientation, socioeconomic status, faith, profession, tastes, disability, age, as well as race and ethnicity (Truong et al. 2014). For example, Al-Eraky et al. (2014) study in Arabian countries identified the ‘‘Four-Gates’’ of medical professionalism: Dealing with Self, Dealing with Tasks, Dealing with Others, Dealing with God. The final Gate includes two elements central to Arab culture, rooted in faith: Self accountability for themselves (taqwa) and self-motivation – expect reward from God, not people (ehtesab). It is important therefore to importance of working in acknowledge the this when Arabian countries, and similarly, when doctors from Arabian countries move to the West (or elsewhere) they will need to be aware not to impose their own beliefs on patients and also to consider where their (non-Arabian) colleagues’ motivations and beliefs may come from, as these may not be faith based.

Cultural competency – ‘‘it’s more than empathy’’

학생이나 의사가 한 사회에서, 환자와 가족이 다른 사회에서 온 경우에 의사가 꼭 자신의 가치관이나 규범을 바꿀 필요는 없으나 이 환자 각각에 대해서 더 민감해질 필요가 있다.

Finally, in the situation where a student or doctor is from one ‘‘society’’ (or culture) and the patient/family is from another, the doctor doesn’t necessarily shift their values and norms but must be sensitive to those of each patient,

또한 IMG는 물론 자기 자신의 국가에서 진료하는 의사조차 문화적으로 '안전'하지 못할 수 있음을 알아야 한다.

It is sometimes forgotten that IMGs, and even doctors practicing in their own country, can feel culturally unsafe.

새로운 문화로 여행을 갈 때, 새로운 문화에 들어서는 사람은 질문하고, 면밀히 관찰하고, 미리 무언가를 결론짓지 말아야 한다.

When travelling to a newculture (including situations such as working in a city with large ethnic communities) the person entering the culture needs to ask questions, observe intently and assume nothing.

문화의 영향력을 이해하는 첫 번째 단계는 '모든 곳은 다르다'라는 것을 받아들이는 것이며, 관찰과 질문 기법을 사용하여 어떻게 해야 최선의 행동을 할 수 있을것인지 노력하는 것이다. 열린 관심과 호기심을 가지는 것이 도움된다. 단순히 '내가 지금 무엇을 보고 있으며, 이것이 나의 가치관이나 생각과 어떻게 부합하는가?'라는 질문을 하는 것도 다른 문화를 배우자 하는 모습을 보여주면서 스테레오타입이나 부정확한 가설을 피하는데 도움이 된다. 환자와 상호작용시에 문화에 대한 자신의 이해를 명확히 드러내고 문화를 배우고 그것을 의사결정에 포함시키려는 의지를 갖는 것은 매우 높게 인정받을 수 있다.

A first step to understanding the impact of any culture is to assume that everywhere is different (be a ‘‘social anthropologist in mini- ature’’) and use observational and questioning skills to work out howbest to behave. Being openly interested and curious is beneficial – simply asking ‘‘what am I seeing, and how does this fit with my values and ideas?’’ displays a willingness to learn about other cultures, without making stereotypical and/or inaccurate assumptions. When interacting with patients, being explicit about one’s understanding of their culture, and displaying a willingness to learn and incorporate their culture into decision-making is usually regarded highly positively (Box 3).

---

Med Teach. 2015 Sep;37(9):837-43. doi: 10.3109/0142159X.2015.1044953. Epub 2015 Jun 1.

"Doctors on the move": Exploring professionalism in the light of cultural transitions.

McKimm J1, Wilkinson T2.

Author information

• 1a Swansea University , UK .
• 2b Otago University , New Zealand.

Abstract

As the world becomes "flattened" and travel is easier, doctors and other health professionals move and live around the world in large numbers: some for short periods (such as student electives) others on a longer-term or permanent basis. Similarly, as wider migration patterns play out, all doctors need to learn to work in multi-cultural environments, whether they move countries or work in their "home country". We consider cross-culturalaspects of "professionalism" in terms of medical students' and graduates' assimilation into different cultures and some of the aspects of professional practice that may be problematic where cultural expectations and practices may differ. Specifically we explore professional socialization, identity formation, acculturation and cultural competency as related concepts that help our understanding of challenges for individuals and strategies for curriculum development or support mechanisms.

PMID:

 

26030381

 

[PubMed - in process]