의과대학에서 공감을 유지하기: 가능하다 (Med Teach, 2013) [출력완료]

의과대학에서 공감을 유지하기: 가능하다 (Med Teach, 2013)

Maintaining empathy in medical school: It is possible

IMAN HEGAZI & IAN WILSON

University of Western Sydney, Australia

도입

Introduction

의료에서, 환자에 대한 감정적 반응emotional response은 객관성을 위협하는 것으로 여겨지곤 한다. 그러나 환자들은 진정한 공감empathy를 필요로 하며, 의사들은 공감을 하고자 한다. 이러한 감정과 객관성 사이에서의 갈등을 해소하기 위하여 '프로페셔널한 공감Professional empathy'이란 전적으로 '인지적' 기반을 둔 공감으로 정의되었다. 이 정의는 '다른 사람의 감정적 상태를 직접 경험하지 않고도 정확히 인지acknowledge하는 행위the act of correctly acknowledging the emotional state of another without experiencing that state oneself’ 와 같다.

 

이러한 'detached concern'모델에서는 환자가 어떤 감정적 상태에 있는 것을 아는 것은 '환자가 어떻게 느끼는가how the patient feels'를 아는 것과 다르지 않다. 그러나 공감의 기능은 단순히 감정의 상태에 이름을 붙이는labelling것 이상이며, 무언가를 경험하는 기분이 어떤 것인지를 인식하는 것이다. 공감은 동정/연민sympathy와 종종 혼동되곤 하는데,

• 동정/연민이란 '다른 사람의 감정을 경험하는 것'으로 정의되며,

• 공감이란 '그러한 감정을 수용하고 상상하는 것'으로 정의된다.

일부 저자들은 환자를 '동정/연민'하는 의사들은 환자의 고통을 공유하며, 이는 감정적 피로와 객관성의 상실로 이어진다고 하였다.

In medicine, emotional responses to patients are seen as threats to objectivity. Yet, patients are in need of genuine empathy and doctors would like to provide it. To address this conceived conflict between emotions and objectivity, ‘professional empathy’ was defined on a purely ‘cognitive’ basis. It was defined as ‘the act of correctly acknowledging the emotional state of another without experiencing that state oneself’ (Markakis et al. 1999). This model of ‘detached concern’ assumes that knowing ‘how the patient feels’ is no different from knowing that the patient is in a certain emotional state. However, the function of empathy is to recognise what it feels like to experience something rather than merely labelling emotional states (Halpern 2003). Empathy is sometimes confused with ‘sym- pathy’, which is defined as experiencing another’s emotions; whereas empathy is appreciating or imagining those emo- tions. Some authors indicate that doctors who sympathise with their patients share their suffering which could lead to emotional fatigue and lack of objectivity (Halpern 2003).

어떤 사람들은 공감의 감정적 요소가 동정/연민과 같은 것이라고 말하기도 한다. 임상 상황에서 Stepien and Baernstein 는 문헌에서 사용된 다양한 정의를 합하여 공감의 확장된 정의를 내렸는데, 여기에는 도덕적/감정적/인지적/행동적 차원이 들어간다. 이 네 가지가 조화를 이뤄서 환자의 benefit이 된다.

Others imply that the emotional component of empathy is nothing other than sympathy in context (Lancaster et al. 2002). In the clinical context, Stepien and Baernstein (2006) combined the different definitions within the literature to put forward an expanded definition of empathy, which includes moral, emotive, cognitive and behavioural dimensions. All four dimensions should work in harmony to benefit the patient.

 

 

공감의 힘

The power of empathy

감정적으로 몰입emotionally engage 하는 의사가 환자와 더 효율적으로 의사소통하고, 환자의 coping과 불안을 줄여주고, 치료적 효과를 향상시키며, 전반적으로 더 나은 outcome을 가져온다는 근거가 쌓이고 있다. 반대로 공감이 부족할 경우 환자가 더 불만족하게 되고, 의료과오malpractice로 고소를 당할 가능성이 높아진다.

There is growing evidence that emotionally engaged physicians communicate more effectively with patients thereby decreasing patient patient coping, greater anxiety and improving leading to therapeutic efficacy and an overall better outcome (Rietveld & Prins 1998; Beck et al. 2002). On the other hand, lack of empathy increases patient dissatisfaction and the risk of malpractice suits (Beckman & Frankel 2003).

Halpern 은 난감한 상황에서의 공감의 중요성을 강조했다. 환자-의사 간 갈등이 있는 어려운 환자 혹은 어려운 상황에서 갈등해결접근법conflict resolution approach의 활용이 권장된다. 이를 위해서 의사는 환자 및 보호자와 공감해야 한다. Egener가 말한 바와 같이, 공감은 의사와 환자 사이의 분열을 매워준다bridge the divide. 또한 환자에 대한 부정정 판단이나 의견 충돌을 잠시 치워두는데 도움이 되고, 환자 돌봄의 효과성과과 만족도를 높이는데 도움이 된다. Halpern은 의사가 감정적 반응을 의료를 향상시키는데 활용하는 방법을 묘사한 바 있다.

Halpern (2007) sheds light on the importance of empathy in difficult circumstances. In managing difficult patients and in situations where there is a patient–physician conflict, it is recommended taking a conflict resolution approach. To do so, physicians have to empathise with patients and family members (Fetters et al., 2001; Back & Arnold 2005; Stivers 2005; Elder et al. 2006). As stated by Egener (2003), empathy helps us bridge the divide between clinicians and patients. It also helps us put aside our negative judgement or disagreement with patients and enhances the effectiveness of care and patient satisfaction. Halpern (2003) elegantly illustrates ways by which physicians can capitalise on their emotional responses to enhance medical care.

회의론자들은 만약 의사가 '단순히 공감하는 척 행동하면' 어떤지를 물을 수 있다. Halpern은 이에 대해서 환자는 의사가 진정으로 공감emotionally attuned하고 있는지를 느낄 수 있으며, 환자는 진정으로 공감하는 의사를 신뢰하며 그러한 의사의 진료에 더 잘 따른다고 하였다.

The ‘skeptic’ may even ask if physicians can ‘just behave empathically’ without the emotional response. Halpern (2003) answers this question by emphasising that patients sense whether physicians are ‘emotionally attuned’ and that patients trust ‘emotionally attuned’ physicians and adhere better to their treatment.

여러 연구에도 불구하고, 의학교육자와 의료전문직들 사이에서는 의대생들이 의과대학을 다니는 동안 공감이 저해된다는 것에 대한 우려가 늘고 있다. 일부 연구에서는 이러한 하락이 후반부에 가장 두드러진다고 말하며, 다른 연구자들은 의과대학의 초반에 감소한다고 말한다. 일반적으로 합의된 것은 의과대학 기간에 공감이 하락한다는 것이다. 최근에서야 그러한 하락이 정말 유의미한지, '지나치게 과장된 것'이 아닌지에 대한 의문이 제기되고 있다.

Despite rigorous research, there is still increasing concern among medical educators and medical professionals regarding the decline in medical students’ empathy during medical education (Bellini et al. 2002; Hojat et al. 2004; Sherman & Cramer 2005; Chen et al. 2007; Newton et al. 2008). Some studies suggest that the decline is mostly pronounced in the later years, while others suggest that it occurs in the early years of medical education (Austin et al. 2007; Hojat et al. 2009). The general consensus was that empathy declines during medical education. Only recently have studies started ques- tioning whether such a decline is of significant magnitude or ‘greatly exaggerated’ (Colliver et al. 2010).

방법

Methods

단면연구

This is a cross-sectional study of all medical students enrolled at the University of Western Sydney’s School of Medicine (UWS SoM) during the academic year 2011.

참여자

Participants

자발적/익명/자기보고식 설문

Participation in the study was voluntary and anonymous. All medical students enrolled in first through fifth year in 2011 were eligible to participate in the study. The instrument used (a self-assessment survey) was distributed to medical students between April and June 2011. First and second year students were surveyed in April (towards the beginning of the academic year) during problem-based learning (PBL) classes where attendance was mandatory. Third through fifth year students were surveyed during conference weeks in May and June (towards the middle of the academic year) where attendance was recommended but not mandatory.

도구

Instrument

 

설문지 구성/JSPE-S, 20문항 척도

The research instrument consisted of a survey containing questions on demographics, stage of medical education, previous particular education and level of completion of programmes that aim at promoting personal and professional development (PPD) and an empathy scale. The scale employed to measure empathy among medical students was the Jefferson Scale of Physician Empathy, Student version (JSPE-S) (Hojat et al. 2003). The JSPE-S is a 20-item psycho-metrically validated instrument. Respondents indicate theirlevel of agreement to each item on a 7-point Likert Scale(1 ¼strongly disagree, 7 ¼strongly agree). The JSPE-S totalscore ranges from 20 to 140 with higher values indicating ahigher degree of empathy. 

3개 이상 미응답 항목시 non-responder 처리. 2개 이하는 평균값 사용.

Students who failed to return the survey were considered as non-responders. In addition, surveys with more than two missing responses to the items of the scale were discarded. For those with one or two missing responses, the mean score to their present responses was used to replace the missing ones.

JSPE는 긍정문 부정문이 모두 있어서 '묵종하는acquiescent 응답 스타일'을 낮춰줌

Another advantage to the JSPE is the balance between positively and negatively worded items (10 each). The use of positively and negatively worded items is a method usually used in psychology tests to decrease the confounding ‘acqui- escent response style’, for example, a tendency to constantly agree or disagree with statements (Ray 1979; Hojat et al. 2003).

 

통계분석

Statistical analyses

All computations were done using the IBM SPSS Statistical Software version 20 (IBM Corp., Armonk, NY, USA). Non- parametric tests were used in all analyses due to the absence of normality in the distribution of empathy levels amongst medical students participating in the study. Tests included the Kruskal–Wallis and Mann–Whitney tests.

결과

Results

응답률 Response rates

 

 

 

 

사회인구통계학적 특성 Socio-demographic characteristics

 

기술적 특성 Descriptive characteristics of the scale

 

 

그룹간 비교 Group comparisons of the Jefferson Scale of Physician Empathy scores

 

 

고찰

Discussion

 

공감과 성별

Empathy and gender

우리의 관찰 결과와 마찬가지로 여자 의과대학생이 남자 의과대학생보다 더 JSPE-S점수가 높다. 이러한 성별 간 차이는 모든 학년에서 관찰되며, 다만 여학생이 더 높게 나타나지 않은 일부 연구가 있으며, 이는 표집 편향 때문에 생긴 것으로 설명하곤 했다. 우리의 연구결과는 여성이 공감이 더 높다는 여러 연구결과들과 일치한다.

According to our findings, female medical students scored significantly higher on the JSPE-S than male medical students. These gender differences occurred at all stages of undergradu- ate medical education (i.e. years one to five). While a few studies failed to demonstrate higher empathy scores among female students, reportedly due to sampling bias (Di Lillo et al.2009; Rahimi-Madiseh et al. 2010; Roh et al. 2010; Paro et al.2012), our findings are consistent with the results of a number of studies which suggest that gender differences, in favour of women, exist concerning empathy (Hojat et al. 2001, 2002a,2002b, 2002c, 2003; Austin et al. 2007; Kataoka et al. 2009;Rosenthal et al. 2011). 

공감은 인지적 차원과 정서/감정적 차원이 있다. 인지적 차원은 '환자의 내면의 경험과 관점을 이해하는 능력, 그리고 이러한 이해를 의사소통하는 능력'이며, 정서적 차원은 '환자의 감정과 관점을 상상하는 능력'이다. 성별간 약간의 차이가 있으며, 여성이 조금 더 높게 나오고, 특히 정서적 요소를 측정하는 JSPE에서 그러했다(11개 중 7개). 반대로 성별간 차이가 없었던 문항은 주로 인지적 공감 문항이었다(9개 중 6개).

Empathy encompasses cognitive and affective/emotional dimensions. The cognitive dimension refers to ‘the ability to understand the patient’s inner experiences and perspective, and a capability to communicate this understanding’ (Hojat et al. 2003); whereas the affective dimension refers to the ability to imagine the patient’s emotions and perspectives (Stepien & Baernstein 2006). Significant gender differences, in favour of women, were particularly observed in JSPE items which measured the affective component of empathy (7 out of 11). On the other hand, items which showed no significant differences between genders were predominantly cognitive in nature, that is, items which measured the cognitive component of empathy (six out of nine).

여성이 더 공감이 높은 것에 대해서 여러가지 설명이 있으나, 확정적인 것은 없다. 여성이 감정적 신호에 더 수용적이라고 보기도 하며, 이러한 이유로 (상대방을) 더 잘 이해하게 되고, 더 나은 공감적 관계를 갖게 된다.

Several explanations have been offered for gender differ- ences in empathy, but, none have been conclusive. It has been suggested that women are more receptive to emotional signals than men, which can lead to better understanding and, therefore, a better empathic relationship (Hojat et al. 2002a).

애정과 감정적 지지를 동반한 부모의 양육 스타일이 친-사회적 발달과 공감을 강화시켜주는 것으로 보인다. 반대로, 단호하고 적대적인 양육은 공격성을 촉진한다. Carlo 등은 양육스타일과 성별의 비교를 통해서 애정과 가족의 지지적 관계에 여성이 더 애정에 수용적receptive이라고 보고했다.

Parenting styles characterised by affection and emotional support seem to enhance pro-social develop- ment and empathy. On the other hand, rigid and hostile parenting facilitates aggression. Carlo et al. (1999) analysed parenting styles in relation to gender and reported that girls seem more receptive to affection and support in family relationships.

 

공감과 학년

Empathy and year of medical education

본 연구의 결과에서 학년간 공감의 차이는 없었다. 이는 이전 연구와 다른 결과인데, 비록 통계적으로 유의하지는 않으나 학생들은 학교를 다니는 동안 공감이 더 향상되었다. Kataoka의 단면연구역시 비슷한 결과를 보여준다.

The results of this study showed no significant difference in empathy scores in relation to year of medical course. This finding is contrary to many previous studies which observed a decline in the mean empathy scores, during education, in various health disciplines (Chen et al. 2007; Hojat et al. 2009; Nunes et al. 2011; Ward et al. 2012). Although insignificant, it seems that students may have even developed more empathy as they progressed in their training. A cross-sectional study by Kataoka et al. (2012) showed similar findings in Japanese medical students.

Empathy and Personal and Professional Development

Possible limitations.

Conclusion

Colliver JA, Conlee MJ, Verhulst SJ, Dorsey JK. 2010. Reports of the decline of empathy during medical education are greatly exaggerated: A reexamination of the research. Acad Med 85:588–593.

 

 

 

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Med Teach. 2013 Dec;35(12):1002-8. doi: 10.3109/0142159X.2013.802296. Epub 2013 Jun 19.

Maintaining empathy in medical school: it is possible.

Hegazi I1, Wilson I.

Author information

• 1University of Western Sydney , Australia.

Abstract

BACKGROUND:

Empathy is an indispensable skill in medicine and is an integral part of 'professionalism'. Yet, there is still increasing concern among medical educators and medical professionals regarding the decline in medical students' empathy during medical education.

AIMS:

This article aims at comparing the levels of empathy in medical school students across the different years of undergraduate medicaleducation. It also aims at examining differences in empathy in relation to gender, year of study, cultural and religious backgrounds, previous tertiary education and certain programmes within the curriculum.

METHOD:

The Jefferson Scale of Physician Empathy, Student version (JSPE-S) was employed to measure empathy levels in medical students (years one to five) in a cross-sectional study. Attached to the scale was a survey containing questions on demographics, stage of medicaleducation, previous education, and level of completion of particular programmes that aim at promoting personal and professional development (PPD).

RESULTS:

Four hundred and four students participated in the study. The scores of the JSPE-S ranged from 34 to 135 with a mean score of 109.07 ± 14.937. Female medical students had significantly higher empathy scores than male medical students (111 vs. 106, p < 0.001) across all five years of the medical course. There was no significant difference in the total empathy scores in relation to year of medical education. Yet, the highest means were scored by year five students who had completed personal and professional development courses.

CONCLUSIONS:

Our findings suggest that there is a gender difference in the levels of empathy, favouring female medical students. They also suggest that, despite prior evidence of a decline, empathy may be preserved in medical school by careful student selection and/or personal and professional development courses.

PMID:

 

23782049

 

[PubMed - indexed for MEDLINE]