미국 의과대학생의 번아웃과 전문직다운 행실의 관계(JAMA, 2010)

미국 의과대학생의 번아웃과 전문직다운 행실의 관계(JAMA, 2010)

Relationship Between Burnout and Professional Conduct and Attitudes Among US Medical Students 

Liselotte N. Dyrbye, MD, MHPE / F. Stanford Massie Jr, MD / Anne Eacker, MD / William Harper, MD / David Power, MD, MPH / Steven J. Durning, MD / Matthew R. Thomas, MD / Christine Moutier, MD / Daniel Satele, BA / Jeff Sloan, PhD / Tait D. Shanafelt, MD

기존 연구에서 의과대학생들이 사회적으로 전문직에게 요구하는 기대에 부합하는 전문가적 정체성 발달에 실패하고 있음을 지적한다. 이러한 결과가 우려스러운 이유는 의과대학 기간의 일부 비전문직업적 행동이 이후 의사가 된 이후의 비전문직업적 행동을 예측하기 때문이다.

Research suggests that medi- cal students may fail when attempting to develop a professional identity con- sistent with the expectations of soci- ety and the profession.3-9 These find- ings are concerning because evidence suggests that some unprofessional be- haviors during medical school predict subsequent unprofessional conduct once in practice.10

프로페셔널리즘의 중요성은 널리 인정되고 있지만 어떻게 개인적 스트레스(우울, 낮은 QOL)나 전문직으로서의 스트레스(탈진) 이 프로페셔널리즘과 어떻게 연결되는지는 거의 알려진바가 없다. 기존 연구에서 과도한 스트레스(distress)는 공감능력의 저하 및 의료의 질 저하와 관련됨을 보고한 바 있으며, 이는 과도한 스트레스가 비전문직업적 행동과 태도로 귀결된다는 개념적 프레임워크를 상정posit한다.

Despite the widely acknowledged importance of professionalism, how personal distress (such as depression or low mental quality of life [QOL])and professional distress (such as burnout) relate to professionalism is largely unexplored. Previous studies suggest that distress is associated with decreased empathy11-14 and decreased quality of care,13,15-17 which has led to a conceptual framework that posits that distress can lead to unprofes-sional behaviors and attitudes.14 

METHODS

참여자

Participants

자료 수집

Data Collection

all letters indicated that partici- pation was voluntary, responses were confidential, and data would be ano- nymized. 

Informed consent was im- plied upon return of the survey. No incentive was provided for participa- tion.

연구 척도

Study Measures

탈진, 우울증상, QO

Burnout, Symptoms of Depression, and QOL.

탈진척도: Maslach Burnout Inventory (MBI),

Burnout was measured by the Maslach Burnout Inventory (MBI),18 which is considered the criterion stan- dard.19 Burnout encompasses 3 do- mains

• 정서적 탈진 emotional exhaustion [score range 0-54],
• 비인간화 depersonalization [score range 0-30],
• 개인적 성취 personal accomplishment [score range 0-48]

which have been confirmed in factor analyses.18

탈진은 자살성 사고/유급에 대한 생각/낮은 공감능력 등과 관련됨

Previously dem- onstrated relationships between burn- out and

• suicidal ideation,20
• serious thoughts of dropping out,21 and
• low em- pathy12 among medical students

pro- vide validity evidence.

 

'정서적 탈진' 혹은 '비인간화' 스케일에서의 높은 점수가 임상적 번아웃을 구분할 수 있어서 이분변수화 함.

Because high scores on either the emotional exhaustion ( 27) or depersonalization( 10) scales can distinguish clinically burned out from non–burned out individuals,22 burnout as a dichotomous variable was defined as having high emotional ex- haustion and/or high depersonalization.

 

우울 평가 척도: Primary Care Evalua- tion of Mental Disorders (PRIME- MD)

The 2-item Primary Care Evalua- tion of Mental Disorders (PRIME- MD) was used to screen for depres- sion.23 A positive depression screen is defined as a positive response to either of the 2 items. The PRIME-MD per- forms similar to longer instruments24 and has a sensitivity of 86%to 96%and a specificity of 57% to 75% for major depressive disorder.23,24

QOL 평가 척도: Medical Outcomes Study Short-Form (SF-8, range 0-100)

Quality of life was measured using the psychometrically sound Medical Outcomes Study Short-Form (SF-8, range 0-100)25 with norm-based scor- ing methods used to calculate mental and physical QOL summary scores.25,26 The mean (SD) mental and physical QOL summary scores for the US popu- lation are 49.2 (9.46) and 49.2 (9.07), respectively.25

전문직적 행위와 태도

Measures of Professional Conduct and Attitudes.

치팅/임상에서의 비정직한 행위 문항: 기존 문헌 바탕

Items inquiring about professional conduct and attitudes rep- resentative of professionalism are shown in eBox (available at http://www.jama.com). The items exploring whether students had engaged in cheating/ dishonest clinical behaviors were de- rived from previous studies of medical students.5-8

 

의사의 책임에 관한 문항: Medical Students’ Atti- tudes Toward Providing Care for the Underserved (MSATU) instrument

The items regarding physi- cians’ responsibility to society were de- rived from the Medical Students’ Atti- tudes Toward Providing Care for the Underserved (MSATU) instrument.3,27

 

의과대학생들은 제약업계의 홍보전략에 상당히 노출되며, 전문직으로서 COI를 관리하는 것은 프로페셔널리즘에 중요하므로, 우리는 학생들이 산업계와 적절한 관계가 무엇인지에 대한 관점을 평가하고자 했다. 이와 관련된 항목등르 AMA의 'Ethi- cal Guidelines of Gifts to Physicians from Industry' 항목으로부터 만들어졌다. 학생들에게 제약업계나 산업체가 스폰서를 하는 행사에서 다양한 선물을 받는 것에 대해서 질문을 했다. 항목들은 AMA policy에서 거의 문자 그대로 따왔다.

Because medical students have sub- stantial exposure to the promotional tactics of the pharmaceutical indus- try4 and managing professional con- flicts of interest is an important aspect of professionalism, we included items assessing students’ views regarding what represented appropriate relationships with industry. These items regarding conflicts of interest in relationships with industry were derived from the Ameri- can Medical Association (AMA) Ethi- cal Guidelines of Gifts to Physicians from Industry.29,30 Students were asked about the appropriateness of accept- ing various gifts from pharmaceutical representatives or attending industry- sponsored events. These items were taken nearly verbatim from the AMA policy.29,30

 

AMA는 다음의 것은 엄격하게 금지하고 있으며, 다만 교재를 제공받거나 작은, 비-교육관련 선물(펜 등)은 허용가능하다

• Accepting $500 after com-pleting a short survey,
• attending din- ner at an expensive restaurant, or
• ac- cepting movie coupons or meals from pharmaceutical representatives

are spe- cifically banned by the AMA policy while accepting textbooks (eg, pocket antimicrobial book) and small, non- educational gifts (eg, pens) are allow- able under the AMA policy.

통계 분석

Statistical Analysis

 

Standard descriptive summary sta- tistics were used to characterize the sample. Differences in a dependent out- come variable by independent vari- ables were evaluated using the Kruskal- Wallis test (continuous variables) or 2 test (categorical variables) as appropri- ate. All tests were 2-sided with type I error rates of .05. Participants were ex- cluded from individual analyses if their data involved in the comparison were missing.

 

 

 

Bivariable logistic regression was per- formed to evaluate the relationship be- tween burnout and individual cheating/ dishonest clinical behaviors, attitudes toward appropriate relationships with industry, and beliefs about physicians’ responsibility to society.

• For multivari- able analysis, forward stepwise logis- tic regression was performed to evalu- ate associations of all independent demographic and distress variables with engaging in 1 or more cheating/ dishonest clinical behaviors and dis- agreeing with 1 or more of the respon- sibility to society items. 
• Logistic regression with backward stepping con- firmed results of the initial stepwise re- gression. In both forward and back- ward stepping models, a significance level of .05 was used as an entry thresh- old.
• Saturated models that included all of the variables confirmed the find- ings of the stepwise models.
• Because each school has its own culture, method for selecting matriculates, learning en- vironment, and curriculum, we also re- peated the multivariable analysis and controlled for site (school) in the model. All analyses were conducted using Linux SAS 9.2 (SAS Institute Inc, Cary, North Carolina).

RESULTS

 

Professional Conduct, Relationships With Industry, and Views Regarding Physicians’ Responsibility to Society

프로페셔널리즘과 번아웃

Professionalism and Burnout

Table 2. Self-reported Behaviors and Attitudes Among Medical Students With and Without Burnout

프로페셔널리즘과 과도한 스트레스

Professionalism and Personal Distress

 

 

Multivariable Analysis에서 프로페셔널리즘과 관련된 요인

Factors Associated With Professionalism on Multivariable Analysis

 

Table 3. Multivariable Analysis of Factors Independently Associated With Self-reported Cheating/Dishonest Clinical Behaviors and Less Altruistic Professional Values

 

COMMENT

본 대규모의 다기관 연구에서, 자기보고식 cheating and dishonest clinical behaviors 가 번아웃과 직접적으로 관련이 있음을 보여주었다. 한편 의사의 사회적 책임과 관련한 전문직의 이타적 가치는 번아웃과 역의 관계에 있었다.

 

번아웃의 ...

• 비인간화 영역은 AMA의 정책과 부합하지 않는 산업계와의 관계를 맺는 것을 받아들이는 것과 관련되어 잇었다.
• 반대로 우울 영역이나 정신적/신체적 QOL은 임상에서의 부정행위/부정직행위, 산업계에 대한 태도, 이타적인 전문직으로서의 가치와 관계가 거의 없었다.

 

이러한 결과는 번아웃이 주로 프로페셔널 영역에 영향을 주는 한편 개인 수준의 과도한 스트레스는(낮은 정신적 QOL) 개인적 영역(인간관계의 어려움, 약물 남용)에 보다 더 큰 영향을 미친다는 이론적인 프레임워크와 부합하며, 이 때 프로페셔널 역역의 이차적 효과는 그 만성화 정도chronicity나 심각도severity에 따라 달려 있다.

 

In this large, multi-institutional study, self-reported cheating and dishonest clinical behaviors showed a direct as- sociation with burnout, while altruis- tic professional values regarding phy- sicians’ responsibility to society showed an inverse relationship with burnout. The depersonalization domain of burn- out was also associated with the belief that it is acceptable to engage in rela- tionships with industry that are incon- sistent with the AMA policy state- ment. In contrast, there were few relationships between depression or mental/physical QOL and cheating/ dishonest clinical behaviors, attitudes toward industry, or altruistic profes- sional values. These findings are in keeping with the theoretic frame- work18 that burnout primarily affects the professional domain, whereas per- sonal distress (such as a low mental QOL) often has greater initial effect on personal domains (eg, relationship dif- ficulties or substance abuse), with a sec- ondary effect on the professional do- main depending on chronicity and severity.

학생들이 부정직한 행위에 대해서 그것의 부적절성을 알면서도 그러한 행위를 하는 것은 부정직을 촉진하는 학습 환경의 요소와 관련이 있을 수 있다. 학생들은 신체검진을 충분히 하지 않고도 신체검진 결과를 거짓으로 보고하는 것 등의 상황을 만들 수 있다. 학생들의 평가에 대한 두려움과 팀에 들어맞기fit in 위한 열망에 더하여, 본 연구에서는 번아웃이 전문직답지 못한 행위에 기여하는 중요한 변인일 수 있음을 제기한다.

The fact that students fre- quently engage in dishonest behaviors despite knowing they are inappropri- ate may imply that some elements of the learning climate foster dishonesty. This could lead to a situation in which stu- dents are more willing to falsely re- port physical examination findings than admit they performed an incomplete ex- amination. In addition to students’ fear of poor evaluations and a desire to fit in with the team,9 this study suggests that burnout may be another impor- tant variable contributing to unprofes- sional behavior.

번아웃된 학생은 의사의 사회적 책무성에 대해서 이타적 관점을 보다 덜 가지며, 이는 프로페셔널한 태도와 advocacy가 professional distress에 취약할 수 잇음을 보여준다.

Students with burnout were also less likely to hold altruistic views regard- ing physicians’ responsibility to soci- ety, suggesting that professional atti- tudes and advocacy may be vulnerable to professional distress.

 

 

 

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JAMA. 2010 Sep 15;304(11):1173-80. doi: 10.1001/jama.2010.1318.

Relationship between burnout and professional conduct and attitudes among US medical students.

Dyrbye LN1, Massie FS Jr, Eacker A, Harper W, Power D, Durning SJ, Thomas MR, Moutier C, Satele D, Sloan J, Shanafelt TD.

Author information

• 1Mayo Clinic College of Medicine, Rochester, Minnesota, USA. dyrbye.liselotte@mayo.edu

Abstract

CONTEXT:

The relationship between professionalism and distress among medical students is unknown.

OBJECTIVE:

To determine the relationship between measures of professionalism and burnout among US medical students.

DESIGN, SETTING, AND PARTICIPANTS:

Cross-sectional survey of all medical students attending 7 US medical schools (overall response rate, 2682/4400 [61%]) in the spring of 2009. The survey included the Maslach Burnout Inventory (MBI), the PRIME-MD depression screening instrument, and the SF-8 quality of life (QOL) assessment tool, as well as items exploring students' personal engagement in unprofessional conduct, understanding of appropriate relationships with industry, and attitudes regarding physicians' responsibility to society.

MAIN OUTCOME MEASURES:

Frequency of self-reported cheating/dishonest behaviors, understanding of appropriate relationships with industry as defined by American Medical Association policy, attitudes about physicians' responsibility to society, and the relationship of these dimensions of professionalism to burnout, symptoms of depression, and QOL.

RESULTS:

Of the students who responded to all the MBI items, 1354 of 2566 (52.8%) had burnout. Cheating/dishonest academic behaviors were rare (endorsed by <10%) in comparison to unprofessional conduct related to patient care (endorsed by up to 43%). Only 14% (362/2531) of studentshad opinions on relationships with industry consistent with guidelines for 6 scenarios. Students with burnout were more likely to report engaging in 1 or more unprofessional behaviors than those without burnout (35.0% vs 21.9%; odds ratio [OR], 1.89; 95% confidence interval [CI], 1.59-2.24).Students with burnout were also less likely to report holding altruistic views regarding physicians' responsibility to society. For example, studentswith burnout were less likely to want to provide care for the medically underserved than those without burnout (79.3% vs 85.0%; OR, 0.68; 95% CI, 0.55-0.83). After multivariable analysis adjusting for personal and professional characteristics, burnout was the only aspect of distress independently associated with reporting 1 or more unprofessional behaviors (OR, 1.76; 95% CI, 1.45-2.13) or holding at least 1 less altruistic view regarding physicians' responsibility to society (OR, 1.65; 95% CI, 1.35-2.01).

CONCLUSION:

Burnout was associated with self-reported unprofessional conduct and less altruistic professional values among medical students at 7 US schools.

Comment in

• Understanding depression and distress among medical students. [JAMA. 2010]
• Medical student burnout and professionalism. [JAMA. 2011]
• Medical student burnout and professionalism. [JAMA. 2011]

PMID:

 

20841530

 

[PubMed - indexed for MEDLINE]