문화권별 의-전문직업성: 의료와 의학교육의 과제(Med Teach, 2014)

문화권별 의-전문직업성: 의료와 의학교육의 과제(Med Teach, 2014)

Medical professionalism across cultures: A challenge for medicine and medical education

Vikram Jha, Michelle Mclean, Trevor J. Gibbs & John Sandars

의과대학 교육과정에서 프로페셔널리즘을 졸업 성과로 기술하지 않은 곳을 찾기는 어려운 반면, 어떻게 프로페셔널리즘을 가르치고 평가할 것인가에 대해서는 차이가 크다. 이는 부분적으로는 프로페셔널리즘을 정의하는 것 자체가 애매한 특성elusive nature를 갖기 때문이다.

While it would be rare to find a medical curriculum in which professionalism was not a stated graduate outcome, there is a wide variation in how profes- sionalism is taught and assessed (Hodges et al. 2011). This is, in part, due to the elusive nature of a definition of profession- alism (Jha et al. 2010; Passi et al. 2010; Aguilar et al. 2011; O’Sullivan et al. 2012),

현재 프로페셔널리즘에 대한 이해는 여러 문헌에서 프로페셔널리즘에 대해서 주로 서구의(앵글로-색슨) 개념을 반영하기 때문에 보다 복잡해지기도 한다. 여러 연구자들은 프로페셔널리즘이 복잡하고 다차원적인 사회적 구인complex, multi- dimensional social construct 으로서, 모든 프로페셔널리즘에 대한 토론에서 맥락/지리적 위치/문화적 주요 고려사항 등을 고려해야 한다고 주장한다.

Our current under- standing of professionalism is further complicated by the fact that the literature largely reflects a Western (Anglo-Saxon) notion of professionalism(Hodges et al. 2011). Several authors have, however, identified professionalism as a complex, multi- dimensional social construct (Ginsburg et al. 2000; Stern 2006; Martimianakis et al. 2009; Cruess et al. 2010; Ho et al. 2011), making context, geographical location and culturally important considerations in any discussion of professionalism (Cruess et al. 2010; Chandratilake et al. 2012).

맥락이 특정하게 제한된 상황에서 프로페셔널리즘을 측정가능한 구인으로 정의하고자 하는 노력은 엄청나게 어려운 것은 아니지만, 지난 수십년간 의과대학생들과 의사들이 국경을 넘나드는 일이 잦아지면서 어떻게 프로페셔널리즘을 정의하고 평가할지가 점차 더 문제가 되어왔다.

If trying to define professionalism as a measurable construct within a particular context is not sufficiently difficult, the increased movement of medical students and qualified health practitioners across the globe over the last few decades has further challenged how we define and assess professionalism.

• 의학교육자들과 의사들의 이동 medical educators and clinicians are also on the move (Hodges et al. 2009; Gibbs & McLean 2011; McKimm & McLean 2011),
• 국제 학생들, 해외 위탁 의과대학 international students and offshoring of medical campuses in, the Middle East and the Caribbean

대중들이 의사와 의대생을 막론하고 점차 더 비전문직업적 행위에 대해서 엄격한 판단을 내리는 성향을 보임에 따라, 문화마다 다양한 의사 환자 관계 혹은 교사-학생 상호작용의 방식들이 "서로 다른" 행동이나 태도가 "전문직답지 못한 것"으로 인식될지를 상상하는 것은 어렵지 않다. 사례로는..

With reports that the public appears to be more judgemental of unprofessional behaviour than either doctors or students (Brockbank et al. 2011), it is not difficult to imagine how in a cross-cultural doctor–patient or a teacher–student interaction, perceptions of a ‘‘different’’ behaviour or attitude might be perceived as ‘‘unprofessional’’. Examples of this include:

• IMG사이의 의사소통 perceived barriers in communication skills amongst International Medical Graduates,
• 효과적 커뮤니케이션을 막는 언어 장벽 language barriers impeding effective communication, 
• 사회적으로 용납되지 않는 행동에 관한 문화적 차이 cultural differences leading to socially unacceptable practices and
• 하나 혹은 그 이상의 집단에 대한 오해와 잘못된 해석 misunderstanding or misinterpretation by one or more parties (Yao & Wright 2001; Dorgan et al. 2009).

Rothwell 등은 해외에서 수련받은 의사들이 환자-의사 관계에 있어서 다른 의사들과 차이를 보이며, 특히 그들의 고국에서보다 위계구조에 있어서 보다 부드러운fluid 태도를 보임을 보고한 바 있다.

In Rothwell and colleagues’ (2013) paper, overseas-trained doctors reported differences in patient–staff relationships, with more fluid hierarchical struc-tures than they were used to in their home countries.

Chandratilake 등은 프로페셔널리즘을 구성하는 것으로 생각하는 태도/신념/행동에 지리적, 지역적 차이가 있다는 근거를 제시하였다. 이들은 전문직으로서 갖춰야 할 자질에 대해서는 어느 정도 합당한 합의가 있지만, 그 자질 중 무엇이 필수적인가에 대해서는 지역적 차이가 있다고 하였다. 이들은 이러한 차이가 사회문화적 요인에 기인해씅ㄹ 것이라고 결론지으며, 반-문화적 반응counter-cultural response의 존재를 제안하였다.

In a study by Chandratilake et al. (2012), there was the evidence of geographical and regional variations in attitudes, beliefs and behaviours believed to constitute profes-sionalism. They found that while there was a reasonable consensus on professional attributes, there were regional differences as to which of the attributes were essential. The authors concluded that differences may be due to socio-cultural factors and suggested the existence of a counter-cultural response, first reported by Schmidt et al. (2004) to explain medical students’conventional perceptions of holism. 

물론 이 분야의 연구가 여러 이해관계자들의 관점을 반영해야 하겠지만, 문화에 대한 어떤 설명을 할 때 '개인'에 초점을 맞춰야 한다는 의견에 동의한다. 여기에 깔린 전제는 문화는 개인이 표현하는 가치/신념/행동을 보여주는데, 이것이 사회적으로 구성된다는 것이다. 예컨대, 더 넓은 범위의 사회에서 하나의 지배적인 문화가 존재한다면, 그 환경 내에 있는 의사는 사회화를 통해 그 문화를 내면화할 것이다. 반대로 지배적 문화가 다양한 경우, 다양한 가치/신념/행동이 학생이나 의사에게 제시될 것이다.

Whilst we agree that future research in this area should include canvassing the views of other stakeholders, e.g. patients and students (Chandratilakeet al. 2012), we are also of the opinion that any exploration of culture pertaining to interactions between medical students and their teachers, doctors and patients, and amongst member of the multiprofessional team should focus on the individual(Goldie 2012). The underpinning rationale is that culture represents the values, beliefs and behaviours expressed by an individual, which are socially constructed. For example, if there is a particular dominant culture in the wider society, then doctors within that context will internalise the culture through socialisation. Diversity in dominant cultures may, on the other hand, result in differing values, beliefs and behaviour being presented to students or doctors (Bennett & Bennett 2004). 

문화간 발달 연속체

Intercultural development continuum

1993년 Bennett 은 문화간 민감성의 발달모델Developmental Model of Intercultural Sensitivity 을 통해서 개인의 문화적 차이에 대한 반응을 묘사하였다. 이 모델은 문화간 발달 연속체intercultural development con-tinuum로 진화하였으며, Hammer는 2011년 "더 넓은 문화간 역량/민감성을 향한 움직임으로서, 문화적 공통점과 차이점에 관한 보다 덜 복잡한 인식과 행동으로부터(monocultural mindset orien-tations), 보다 복잡한 상태로 나아가는 것(intercultural/global mindset)."이라고 하였다. 이는 이(종)문화간 정체성intercultural identity을 구성하기 위해 다음의 단계를 거치게 된다.

In 1993, Bennett proposed a Developmental Model of Intercultural Sensitivity to describe a person’s reactions to cultural differences (Bennett 1993). This model evolved into the intercultural development con-tinuum, described by Hammer (2011) as ‘‘a movement towards greater intercultural competence/sensitivity, from a less com-plex set of perceptions and behaviours around cultural commonalities and differences (monocultural mindset orien-tations) to a more complex set of perceptions and behaviours This continuum therefore(intercultural/global mindset)’’. involves an individual potentially moving from

• 거부 단계 the initial stages of denial,
• 양극화/대립 through polarisation,
• 최소화 minimisation,
• 수용 accept-ance and
• 적응 finally to adaptation,

 

which involves the construction of an intercultural identity. 

문화적 적합성

Cultural fit

Lu 에 따르면, 사회적 수준의 문화는 주류의 경향을 반영하나 모든 개인의 모든 행동을 반영하지는 않는다. 저자는 개인의 문화적 적합성은 그들의 웰빙을 보여준다고 주장한다. 만약 한 개인이 공동의 가치나 행동과 잘 부합하면 그/그녀의 사회환경과의 상호작용은 보다 부드러울 것이고, vice versa.

According to Lu (2006), the culture at a societal level involves mainstream tendencies but does not involve all behaviours  of all individuals. The author contends that an individual’s cultural fit has implications for their well-being. If an individual is in accord with the shared values or behaviours, his/her interactions with the social environment are likely to be smooth

 

앞으로는?

Moving forward?

만약 Bhawuk and Brislin 이 제안한 바와 같이 "(무언가가 혹은 사람이) 다른 문화권에서도 효과적이려면 반드시 다른 문화에 관심을 가져야 하며, 문화적 차이를 인식할 수 있을 만큼 민가해야 하고, 다른 문화의 사람들이 가리키는 방향에 맞춰서 행동을 변화시키고자 하는 의지가 있어야 한다"면, 이는 문화적으로 다른 곳에서 일을 하기로 마음을 먹은 사람들의 책임이며, 그러한 결정이 마주할 도전을 설명하는 것이다.

If, as Bhawuk and Brislin (1992) have suggested that ‘‘to be effective in another culture, people must be interested in other cultures, be sensitive enough to notice cultural differences, and then also be willing to modify their behaviour as an indication of respect to the people of other cultures’’ (p. 416), this places an onus on the individual who has chosen to study or work in a culture different to contemplate the implications of their decision, particularly in terms of the potential challenges they may face.

스스로 자신이 얼마나 tolerant 한지 생각해봐야 한다. 즉, 자신의 문화적 민감성과 역량에 대해서 생각해봐야 하며, 얼마나 자신이 새로운 사회, 문화적 맥락에 적합fit할 것인지 생각해봐야 한다.

One would need to question how tolerant one might be, i.e. one’s intercultural sensitivity/competence (Hammer 2011) and one would also have to project how one might ‘‘fit’’ into a new social and cultural context (Lu 2006).

의료인력에 국제적으로 이동하는 현 시점에서, 글로벌 프로페셔널리즘을 위학 핵심 교육과정이 제시된 바 있다. 아마도 이러한 상황에서 의학교육자들은 글로벌 시티즌으로서 졸업생을 가르쳐야 할 것이며, 그들이 단순히 사회문화적 맥락에 따른 프로페셔널리즘에 대한 다양한 인식을 갖는 것을 넘어서, 다양성을 포용할 수 있는 스스로의 능력에 대해 성찰하는 능력reflexivity을 기르게 해야 하며, 이것은 다양한 인식을 받아들이는 시작점이 될 것이다

With an internationally mobile medical workforce, a core global professionalism curriculum has been suggested (Evert et al. 2010). Perhaps, as medical educators in a world of international travel and migration, we need to be educating graduates who are global citizens (McKimm & McLean 2011), making them aware not only of different perceptions of professionalism across different social and cultural contexts but also developing their reflexivity in terms of interrogating their ability to embrace difference as a starting point to accepting varying perceptions in order to fit in with local needs.

Bennett and Bennett 및 여러 연구에 근거해서 조직 차원에서는 다음을 해야 한다.

Based on the work of Bennett and Bennett (2004) and a number of others (Slowther et al. 2009; Morrow et al. 2013; Rothwell et al. 2013), ways forward from an organisational perspective would include:

• 기관의 다양성 프로필diversity profile을 인정하고 다양한 가치와 신념의 차이가 존재함을 인식함
  Acknowledging the institution’s diversity profile and recognising that differences in values and beliefs will exist. 
• 문홪거 선입견에 따른 라벨링 지양
  Avoid labelling in terms of cultural stereotypes. 
• 다양성 프로필이 그 지역의 지배적 사회/정치/법적 맥락과 잘 맞게끔 하는 것에 발달 초점을 둠(합목적성) 
  Ensuring a development focus to ensure that the diversity profile fits with the dominant local socio-political/legal culture (i.e. fit for purpose).
• 이문화간 발달 연속체를 따라 훈련과 오리엔테이션 제공
  Providing training and orientation that takes into account that individual students and employees may be some- where along the intercultural development continuum, ranging from denial and defence and so not tolerating difference in culture (ethno-centricism) to being able to adapt to the different cultural context (ethno-relativism). The ethno-centric stance may culminate in anger and attempts to control the situation while ethno-relativism will involve tolerance and understanding, allowing for negotiation and discussion so that both parties can learn from each other.

결론

Conclusions

시나리오 1

Scenario 1

Dr A, a Canadian-born gastroenterologist, starts working at a hospital in the Middle East. During his first month, a young man brings his 80-year-old widowed mother to the hospital because she has noticed bloody stools. During the consult- ation, it is the son who communicates with Dr A, rather than the mother, who is not able to speak English. Dr A accepts this, knowing that many elderly patients in the region have a poor command of English.

 

Consent for a colonoscopy is obtained from the patient via her son. The result reveals advanced colorectal cancer. At the follow-up consultation, the young man brings a younger male sibling but not his mother. They ask Dr A for the colonoscopy results, suspecting that the news is not good and not wanting their mother to know. They also state that if their mother requires surgery, they consent. Dr Ais not sure how to proceed.

원칙: 고지에 입각한 동의, 환자의 권리, 비밀유지

Principles: Informed consent, patient rights and confidentiality

코멘터리

Commentary

고지에 입각한 동의, 환자의 권리, 비밀유지는 서구에서는 잘 받아들여지고 소중하게 여겨지는 것이지만, 가족 관계와 사회적 규범을 보존하는 것이 개인의 자율성보다 더 가치로운 것으로 여겨지는 사회에서는 반드시 그렇지는 않다. 이러한 사회에서는 여러 의사결정이 집단적collective이며, 가족/부족/커뮤니티 수준에서 결정된다. 이 시나리오의 사회-문화에서 아들은 가족 내에서 여성(어머니)를 보호하고자 한다.

Informed consent, patient rights and confidentiality, accepted and enshrined Western constructs, are not always given the same weight in some societies in which preserving family relationships and social norms are valued more than individual autonomy. Many decisions are collective, being made at the family, tribal or at community level (Berg et al. 2001; del Carmen & Joffe 2005). In the socio-culture depicted in this scenario, the son is expected to protect the women in his family.

사우디아라비아에서 병원들이 겪는 주된 윤리적 문제에 대해서 Alkabba 등은 top 10 문제 중 환자의 권리/비밀유지/고지에 입각한 동의를 꼽았다. 그러나 고지에 입각한 동의나 비밀유지와 같은 서구적 개념에 대한 이러한 저항challenge이 비단 한 지역에서의 문제는 아니다. 파키스탄 역시 대체로 이슬람 국가이며, Humayun 등은 대부분의 이들 원칙이 거의 지켜지지 않으며, 저자들은 파키스탄을 비롯한 많은 아시아 문화권의 가부장주의적 모델paternalistic model를 그 원인으로 지적했다. 우간다에서는 Baigana 등이 아프리카의 '우분투' 철학이 "한 사람은 다른 사람의 결과로 존재하는 것이다"를 가지고 있기에, 의과대학생들에게 비밀유지confidentiality를 지키게 만들지 않으며, 대신 환자의 친척들로 하여금 그들이 환자의 정보에 대한 접근이나, 의학적 의사결정에 참여할 수 있는 권리를 허한다.

In a review of the major ethical challenges facing hospitals in Saudi Arabia, Alkabba and colleagues (2012) reported patients’ rights, confidentiality and informed consent amongst the top 10 challenges in terms of the commonly accepted principles of professionalism. These ‘‘challenges’’ to Western perceptions of informed consent and confidentiality are, confined In however, not to one geographic region. Pakistan, which is also largely Islamic, Humayun and col- leagues (2008) reported the almost complete lack of these principles, which the authors ascribe to a paternalistic model of patient care in Pakistan and many other Asian cultures. In Uganda, Baigana and colleagues (2010) reported that the African Ubuntu philosophy of one being as he/she is as a result of others, not only made medical students less likely to practice confidentiality compared with students in the West but also allowed relatives of patients to believe that they had the right to access patient information and to be involved in medical decision making.

문화는 shared decision making에 대한 환자의 기대 수준이나 관여에도 영향을 준다. Yousuf 등은 말레이시아와 인도에서의 연구로부터 의사들이 환자(특히 여성환자)를 보호하기 위해서 진실truth를 딱 필요한 만큼만 제시함을 발견하였다. 이들 의사들은 '환자들은 진짜로 의사결정에 참여하기를 원하는 것이 아니다'라고 가정하고 있다. Barr의 에스토니아 연구에서 환자들은 그들이 진료의 구체적 사항에 대해서 알 권리가 있다는 인식을 못하며, 종종 병환에 대한 정보를 충분히 제공받지 못한다.

Cultures also vary with regard to patient expectations and involvement in shared decision making. In Yousuf and colleagues’ (2007) study in Malaysia and India, doctors were found to be economical with the truth to ‘‘protect’’ patients, particularly females. The doctors also assumed that patients did not really wish to be involved in decision making. In Barr’s (1996) Estonian study, patients were not aware of their right to know details of their care and were often not informed of their illnesses.

 

중동에서 수행된 연구에서 Al-Eraky and Chandratilake 는 ABIM의 프레임워크에 일곱 번째 영역, professional autonomy를 새롭게 만들 것을 권고하며, 이 지역에서는 의사결정에 있어서 권력의 균형이 환자가 아니라 의사에 맞춰져 있다고 주장했다.

In a study conducted in the Middle East involving the American Board of Internal Medicine professionalism frame- work, Al-Eraky and Chandratilake (2012) suggesting adding a new seventh domain, professional autonomy, claiming that in this region, the power balance in the decision-making process is in favour of the doctor rather than patients.

Recommendations

시나리오 2

Scenario 2

Dr B, who was born in South East Asia, has completed her medical degree in her home country. She was a diligent student, always following her seniors’ advice. In particular, the professors at her medical school were treated with utmost reverence and, in the eyes of students and patients, they could do nothing wrong. In her first job in the UK, Dr B is placed on a team to work with Professor P, a very senior Professor of Medicine who is also the Head of Department. He is known to have a bad temper. During a ward round one morning, Professor P is rude to the senior nurse. When he finds a patient who he has specifically come to see is not on his bed, he turns to Dr B, shouting: ‘‘It is your job as a house officer to ensure that all patients are ready to be seen once I am on the ward’’. The patient concerned needs his warfarin dose adjusted. Professor P snatches the prescription chart and increases the dose of warfarin. When Professor P leaves, Dr B realises that the dose is too high. She decides not to question Professor P’s decision. He is, after all, the expert and a senior colleague and, back home, she would not challenge him.

원칙: 위계구조와 위계에 대한 도전

Principles: Hierarchical structures and challenging senior colleagues

Commentary

많은 서구 국가(캐나다, 미국)와 달리 아시아 국가들은 임상 근무환경에서 특히 엄격한 위계구조를 보여주고 있으며, 이는 서구적 맥락에서 '프로페셔널한 행동'으로 여겨지는 일부 측면의 발달이나 발현을 억제한다. Kobayashi 등의 연구에서 일본에서 시니어를 향해 목소리를 높이는speaking up 것은 받아들여지지 않으며, 이것이 개개인들이 다른 사람의 전문직답지 못한 행동을 목격하고도 이에 대응하지 못하는 요인이라고 지적했다 또한 일본 의사와 달리 미국 시니어 의사는 주니어 의사의 질문을 보다 더 장려하였다.

Compared with many Western countries, e.g. the USA and Canada, Asian countries in particular, have a stricter hierarchical reporting structure in the clinical workplace, impede which may the development/exhibition of some aspects of what would be considered professional practice in a Western context. In Kobayashi et al.’s (2006) study, the unacceptability of speaking up in front of seniors in Japan was a factor inhibiting individuals from challenging unprofessional behaviour they had witnessed. In addition, compared with their Japanese colleagues, US seniors were much more encouraging of questions from juniors.

터키에서 Ozan 등은 유사한 조직적 위계를 발견하였고, 지지적 환경이 존재하지 않는 것이 의과대학생들의 윤리적 문제에 대한 결심resolution을 제한시킨다고 보고했다. 윤리적 문제에 직면했을 때, 학생들은 교사보다 친구나 선배 학생과 그것을 논의하는 편이다. 같은 연구에서 학생들은 선배 학생의 전문직답지 못한 행동을 보고하는 것을 꺼려했다.

In Turkey, Ozan and colleagues (2010) found a similar organisational hierarchy and reported the lack of a supportive environment limited medical students’ resolution of ethical problems. When faced with ethical issues, e.g. rational use of medicine, drug promotion by pharmaceutical companies, confidentiality or malpractice, students were more likely to discuss these issues with friends or senior students than with their teachers. In the same study, students also failed to report poor professional behaviour amongst seniors.

Recommendations

시나리오 3

Scenario 3

Student C, a fourth year medical student in the UK, chooses to undertake an elective in a far Eastern country, staying with his parents’ family friends who are doctors. Their son, Student M, is a medical student and a friendship develops between the two. Whilst studying together, Student C is shocked to find that Student M copies and pastes large sections froma standard text into his assignment without referencing the original.

원칙: 표절

Principles: Plagiarism

Commentary

 

인도에서의 연구가 보고한 바와 같이 학업적 부정직행위와 관련한 교육이 없는 것이 부정행위가 발생하는데 기여했을 수 있지만, 어떤 문화권에는 북미나 영국에서 수련받은 사람이 보기에는 unprofessional한 행동임에도 그 문화권에는 "문화적으로 뿌리내린" 행동이 있다. 예컨대, 부정행위나 학업적 비정직행위는 크로아티아 학생들에게 흔하고 받아들여진다. Taradi 등의 연구에서 표절은 경고할 만한 수준으로 퍼져 있었다. 이러한 현상은 국가의 빈곤한 사회경제적 구조에 따른 것으로 볼 수 있는데, 전쟁과 더 큰 사회적 수준에서의 부패가 만연한 것에서부터 생기기 때문이다 또한 잡혔을 때 적절한 제재가 없는 것도 한 이유이다.

While the lack of training around academic misconduct may contribute to cheating, as reported for medical students in India (Babu et al. 2011), there is ‘‘culturally engrained’’ behaviour in some contexts that would be deemed unprofessional by someone trained in North America or the UK. For example, cheating and academic dishonesty appears to be commonplace and acceptable amongst Croatian medical students (Bilic´-Zulle et al. 2005; Kukolja et al. 2010; Taradi et al. 2012). In Taradi et al.’s paper (2012), the prevalence of plagiarism was alarming, with most of the 761 students surveyed admitting to educational dishon- esty. Possible reasons for these high figures were the country’s poor socio-economic structures as it emerged from war and the prevalence of corruption within the wider society. Also, a perceived lack of sanctions for those caught cheating meant that students persisted with the practice.

언어 능력이 부족한 일부 학생에게 복사-붙이기는 외국어로 작문을 하는 것보다 쉽다. Vance의 관점에서 "표절은 문화적으로 구성되는 다양한 인식을 포함하는 실로 복잡한 주제이다"라고 썼다. 또 다른 것으로는 유교의 영향을 받은 사회에서는 어떤 "생각"을 그것을 처음 한 사람이 소유권을 가지는 것으로 보지 않고, 그 사회의 총체적인 지식의 한 부분으로서 보기 때문에, 이러한 타인의 생각을 원문 그대로 사용하는 것은 그것을 소유한 사람에게 존중을 표하는 것으로 인식되며, 그 출처를 밝히는 것은 독자의 지적능력을 모욕하는 것으로 인식되기도 한다(정보를 아는 것은 그 정보의 출처를 아는 것으로 이해되므로) .

For some students with poor language skills, copying and pasting was easier than writing in a foreign language (Taradi et al. 2012). In Vance’s (2009) view, however, ‘‘plagiarism is actually a complex subject that involves many culturally constructed notions’’. In other instances, such as in Confucian- influenced societies, rather than perceiving ideas as the property of the originator, they are seen as being part of the collective knowledge of the society and so reproducing these ideas in the original format is perceived as paying respect to the owner and citing the source might be an insult to the intelligence of the reader as knowing the information is recognised as knowing the source (Vance 2009).

Recommendations

시나리오 4

Scenario 4

Student D was born in a country in Eastern Europe that was previously a part of the Soviet Block. He moved to the UK as a child, to be brought up by his uncle. Unfortunately, he does not secure a place in a medical school in the UK despite good grades. He decides to go to Eastern Europe to study medicine in a school where his father’s friend is a Professor of Medicine. Student D’s father has always been proud of his son and takes an active interest in his medical studies. It is no surprise, therefore, to find that two weeks before his final examinations, his father arrives from his hometown. What surprises Student D, however, is that his father has already presented the Dean with a Rolex watch, thanking him for looking after his son. Even worse, the Dean has accepted the watch! His father has also asked his friend, a professor, to find out the questions to the examination Student D is due to take.

원칙: 호의의 댓가로 선물 받기

Principle: Accepting gifts in return for favours

 

 

Commentary

SES가 낮은 조건에서는 부패가 더 일어나기 쉽고 더 쉽게 받아들여진다. 의사들이 경제적으로 부유하지 못한 일부 개발도상국에서 그러한 비전문직업적 행위의 원인이 될 수 있다. 예컨대, 가난한 에스토니아 의사들 일부는 환자들에게 선물을 받는 것을 당연하게 받아들였다considered acceptable. 남아프리카 연구에서 Rooyen은 의과대학생들은 이타적이 되면서 전문직으로서 경재적으로 우아한 삶을 사는 것의 균형을 잡는 것이 어려움을 표했다.

Low socio-economic conditions make corruption more likely and acceptable in some countries. The relative lack of financial well-being of doctors in some developing countries may contribute to an unprofessional behaviour. For example, amongst poorly paid Estonian doctors, accepting gifts from patients was considered acceptable (Barr 1996). In a South African study, van Rooyen (2004) reported that medical students expressed the opinion that being altruistic and achieving a balance between being professional and making a decent living financially was difficult because of the tension between running the business of medical care and earning a decent living.

Recommendations

Chandratilake M, McAleer S, Gibson J. 2012. Cultural similarities and differences in medical professionalism: A multi-region study. Med Educ 46:257–266.

Cruess SR, Cruess RL, Steinert Y. 2010. Teaching professionalism across cultural and national borders: Lessons learned from an AMEE workshop. Med Teach 32(5):371–374.

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Med Teach. 2015 Jan;37(1):74-80. doi: 10.3109/0142159X.2014.920492. Epub 2014 Jul 30.

Medical professionalism across cultures: a challenge for medicine and medical education.

Jha V1, Mclean M, Gibbs TJ, Sandars J.

Author information

• 1University of Liverpool , UK .

Abstract

BACKGROUND:

The recognition of medical professionalism as a complex social construct makes context, geographical location and cultureimportant considerations in any discussion of professional behaviour. Medical students, medical educators and practitioners are now much more on the move globally, exposing them to cultural and social attitudes, values and beliefs that may differ from their own traditional perceptions ofprofessionalism.

AIMS AND METHODS:

This paper uses the model of the intercultural development continuum and the concept of "cultural fit" to discuss what might transpire when a student, teacher or doctor is faced with a new cultural environment. Using our own experiences as medical educators working abroad and supported by evidence in the literature, we have developed four anecdotal scenarios to highlight some of the challenges that different cultural contexts bring to our current (Western) understanding of professionalism.

RESULTS AND CONCLUSIONS:

The scenarios highlight some of the potentially different regional and/or cultural perspectives and nuances of professional behaviours, attitudes or values that many of us either take for granted or find difficult, depending on our training and socio-cultural upbringing. With this paper, we hope to start a long overdue conversation about global professionalism amongst medical educators, identify potential areas for research and highlight a need for medical schools to embrace a "global" approach to how professionalism is embedded in their curricula.

PMID:

 

25073712

 

[PubMed - indexed for MEDLINE]