미국 의과대학 입학생의 불확실성에 대한 내성 (Acad Med, 2014)

미국 의과대학 입학생의 불확실성에 대한 내성 (Acad Med, 2014)

Ambiguity Tolerance of Students Matriculating to U.S. Medical Schools

Marie Caulfield, PhD, Kathryn Andolsek, MD, MPH, Douglas Grbic, PhD, and Lindsay Roskovensky

앞으로 다가올 삶의 우울한 특징은 우리의 과학과 예술 뿐 아니라 우리를 사람으로서 존재하게 하는 희망과 공포에 대한 것들에까지 존재하는 불확실성이다. 절대적 진실에는 도달할 수 없ㄷ으며, 우리는 부서진 일부를 찾는데 만족해야 한다. - 윌리암 오슬러

A distressing feature in the life of which you are about to enter … is the uncertainty which pertains not alone to our science and art, but also to the very hopes and fears which make us men. In seeking out the absolute Truth we aim at the unattainable, and must be content with finding broken portions. —Sir William Osler1

지난 수십년간 수많은 문헌에서 불확실성에 대한 내성이 의사의 중요한 역량이라고 해왔다.

A substantial body of literature over the past several decades suggests that tolerance for ambiguity is an important competency for physicians.2–4 As Geller4 recently pointed out, 

진료에서 개개인의 불확실성에 대한 낮은 내성은 검사 오더를 더 많이 내리게 만드는 결과를 가져오고, 근거중심 가이드라인을 따르지 않는 결과를 가져온다. 스크리닝 맘모그램의 recalling이 높아지고, 환자 비용이 높아지고, 유전자 검사의 음성 결과를 withhold하고, 오진에 따른 소송에 대한 공포가 높아지고, 죽음과 애도에 대해서 불편해하게 된다.

in medical practice, an individual’s low tolerance for ambiguity has been associated with … increased test- ordering tendencies and failure to comply with evidence-based guidelines,5 greater likelihood of recalling screening mammograms,6 increases in patient charges,7 withholding negative genetic test results,3 fear of malpractice litigation and defensive practice,8 and discomfort in the context of death and grief.9,10

불확실성에 대한 낮은 내성이 안좋은 결과를 가져오는 것과 함께, 높은 내성은 낮은 내성으로 인한 안좋은 결과를 줄임과 동시에 반대로 좋은 결과를 가져온다.

In addition to negative factors related to low tolerance for ambiguity, there also may be specific positive factors related to having a high tolerance for ambiguity, in addition to minimizing the negative factors

각 기관에서 강조하는 것.

• 의과대학 입학생 The Association of American Medical Colleges (AAMC) includes tolerance of and adaptation to stressful or changing environments as part of the Resiliency and Adaptability competency, which is one of the core competencies for entering medical students.17 
• 의과대학 졸업생 It also includes comfort with ambiguity in its published Core Entrustable Professional Activities,18 believed essential for graduated students entering residency programs. 
• 소아과 레지던트의 milestone The Accreditation Council for Graduate Medical Education (ACGME) considers tolerance for ambiguity as an essential “reporting milestone” under the Professionalism competency for pediatrics residents19;

분명히, 우리가 아는 어떤 연구도 학생의 불확실성에 대한 내성을 종단적으로 분석한 적은 없다. 독일에서 의과대학 지원자를 대상으로 한 단면연구가 평균 이하의 내성을 확인시켜준 바 있으나, 서로 다른 학년 사이에 차이는 없었다.

Notably, no studies that we know of followed students longitudinally to examine stability of tolerance for ambiguity over time; a cross-sectional study that assessed students enrolled in medical school in Germany20 found below-average tolerance for ambiguity, with no differences across the students enrolled in the different years of school during that academic year.

전공 선택에 대한 영향에 대한 연구 결과는 다양하다.

Empirical studies have produced mixed findings regarding whether tolerance for ambiguity influences specialty preference.4

1993년 Geller 등은 불확실성에 대한 내성에 관한 변형된 스케일을 개발하였다. 이 저자들은 Budner의 정의를 사용하였다. 

In their 1993 study, Geller et al3 developed a modified scale for tolerance for ambiguity. The authors quote Budner’s24 definition of intolerance for ambiguity: 

“the tendency to perceive situations that are novel, complex or insoluble, as sources of threat.” 

그들은 18개의 설문 문항을 병합하였고, 국가 설문조사에 포함시켰다. 이중 7개 문항이 'good fit'을 보였다.

They combined 18 survey items from various measures developed in prior research and included them in a national survey of physicians’ knowledge and attitudes about genetic testing. 

Psychometric analyses found that 7 of the 18 items were a “good fit” for the data.

Purpose and hypotheses

2013년 처음으로 MSQ에 불확실성 내성(TFA) 스케일이 포함되었다.

In 2013, the modified tolerance for ambiguity (TFA) scale described above was, for the first time, included in the AAMC Matriculating Student Questionnaire (MSQ).25 Our study,

Participants and procedures

MSQ에는 다양한 설문문항이 포함된다. 2013년, 미국 내 140개 의과대학에 합격한 모든 학생에게 MSQ에 참여하도록 권고.

The MSQ contains a wide range of survey items, 

• including premedical experiences, 
• the medical school selection process, 
• personal characteristics and attitudes, and 
• specialty preferences and career plans. 

In 2013, individuals accepted for admission to any of the 140 U.S. medical schools that were accredited at that time by the Liaison Committee on Medical Education and that enrolled students in 2013 were invited by the AAMC to participate in the MSQ between June and mid- September.

Measures 

구성은 7개 문항

The seven-item TFA3 scale is a measure of one’s ability to cope with situations of uncertainty.

높은 점수가 높은 내성

Thus, higher scores are correlated with higher tolerance for ambiguity.

스트레스 인식 조사인 PSS도 MSQ에 포함됨. 이것은 10개 문항, 4점척도. 

The Perceived Stress Scale (PSS)26 is widely used for measuring the perception of stress. This 10-item scale measures the degree to which situations in one’s life are considered stressful. The PSS was included in the 2013 MSQ. PSS scores are calculated by summing across the 10 items, which are measured on a 0- to 4-point scale (never = 0, very often = 4).

TFA scale item 

• It really disturbs me when I am unable to follow another person’s train of thought. 
• If I am uncertain about the responsibilities involved in a particular task, I get very anxious. 
• I am often uncomfortable with people unless I feel that I can understand their behavior.
• Before any important task, I must know how long it will take. 
• I don’t like to work on a problem unless there is a possibility of getting a clear-cut and unambiguous answer. 
• The best part of working on a jigsaw puzzle is putting in that last piece. 
• A good task is one in which what is to be done and how it is to clear.

'일차의료, 취약지에서 일할 의사가 있는가?' 문항도 포함됨

The survey also included the following item: “Do you plan to work primarily in an underserved area?” Response options were yes, no, and undecided.

Analytical approach 

신뢰도 분석(Cronbach alpha)

We first examined the internal consistency of the TFA and PSS scales using the Cronbach alpha test of reliability.27

남성과 여성의 차이가 줄어든 것은 밀레니엄 세대의 특징일 수 있다. (1980년~1999년 사이 출생) 이들 세대에서는 성 역할과 성 간 구분이 사라진다.

The narrowing of any difference between men and women may be due to the generational influences of the “Millennial generation.” Ninety- eight percent of the 13,867 survey participants who responded to the TFA items are in the Millennial age group of those born between 1980 and 1999. Some research suggests that gender distinctions and gender roles may be diminishing among those in the Millennial cohort.29

취약지에 근무하고자 하는 학생은 불확실성에 대한 내성이 높았다. 의료 접근성에 대한 격차가 커지고 SES, 인종, 민족, 지역에 따라 그 차이도 커지면서 의료취약지에 거주하는 사람들을 위한 의료인력에 대한 요구가 지속될 것이다. 따라서 의과대학은 TfA가 높은 학생을 입학절차에서 우선순위로 삼아야 한다.

Respondents who expressed an interest in working in an underserved area had higher tolerance for ambiguity than those who did not express such an interest. With disparities of health care access and outcomes recognized by socioeconomic status, race and ethnicity, and geography, there will continue to be a need for clinicians dedicated to patients living in underserved areas.30,31 Therefore, medical schools committed to addressing these problems may consider prioritizing personal characteristics such as tolerance for ambiguity in the admission process to enhance the likelihood that the future health care workforce will better address disparities in health care access.

이번 연구가 어떤 전공을 선택하느냐에 대해서 어떤 예측을 하는가를 보여주진 않았지만 설명적 분석 결과는 일관된다. 예컨대 TFA가 높은 학생들이 선호하는 분야는 의학유전학, 응급의학, 정신건강의학 등이었다.

Although the present study did not make predictions about which specialty preferences would be associated with different levels of tolerance for ambiguity, the exploratory analysis was consistent with some prior work in this area. For example, we found that the specialty preferences associated with the highest levels of tolerance for ambiguity included medical genetics, emergency medicine, and psychiatry;

스트레스에 대한 인식 역시 TFA와 연관되어 있었고, 스트레스를 많이 느낄수록 TFA가 낮았다.

Perceived stress was also associated with tolerance for ambiguity, as students with lower tolerance for ambiguity reported higher perceived stress levels.

의과대학생의 스트레스에 대한 대부분의 프로그램이 정신건강 서비스와 웰니스 프로그램이다. 그러나 이런 프로그램이 TFA 수준에 따라서 똑같이 효과적일지 혹은 이러한 프로그램이 TFA를 높일 수 있을지는 아직 모른다.

Most interventions to address medical student distress have focused on access to mental health services and wellness programs38; cognitive, behavioral, and mindfulness-based strategies39; and, more recently, curricular changes.40 It is

unknown whether these interventions are equally efficacious for students with different levels of tolerance for ambiguity or, relatedly, whether such interventions could increase an individual’s tolerance

25 Association of American Medical Colleges. 2013 MSQ All Schools Summary Report. ttps://www.aamc.org/data/msq/. Accessed July 9, 2014.

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Acad Med. 2014 Nov;89(11):1526-32. doi: 10.1097/ACM.0000000000000485.

Ambiguity tolerance of students matriculating to U.S. medical schools.

Caulfield M1, Andolsek K, Grbic D, Roskovensky L.

Author information

• 1Dr. Caulfield is manager of data operations and services, Association of American Medical Colleges, Washington, DC. Dr. Andolsek is professor of community and family medicine, Duke University School of Medicine, Durham, North Carolina. Dr. Grbic is senior research analyst, Association of American Medical Colleges, Washington, DC. Ms. Roskovensky is senior database specialist, Association of American Medical Colleges, Washington, DC.

Abstract

PURPOSE:

To examine the psychometric adequacy of a tolerance for ambiguity (TFA) scale for use with medical students. Also, to examine the relationship of TFA to a variety of demographic and personal variables in a national sample of entering U.S. medical students.

METHOD:

The authors used data from the 2013 Association of American Medical Colleges Matriculating Student Questionnaire in which questions on TFA were included for the first time that year. Data from 13,867 entering medical students were analyzed to examine the psychometric properties of the TFA scale. In addition, the relationships of TFA to sex, age, perceived stress, and desire to work in an underserved area were analyzed. Finally, the relationship of TFA to specialty preference was examined.

RESULTS:

The TFA scale was found to be psychometrically adequate for use in a medical student population. TFA was found to be higher in men and in older students. Lower TFA was associated with higher perceived stress levels. Students with higher TFA were more likely to express desire to work in an underserved area. Different levels of TFA may be associated with certain specialty preferences.

CONCLUSIONS:

These findings support the assessment of TFA to understand how this personal characteristic may interact with the medical school experience and with specialty choice. Longitudinal work in this area will be critical to increase this understanding.

PMID:

 

25250742

 

[PubMed - indexed for MEDLINE] 

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