Articles (Medical Education)

프로페셔널하지 못한 행동에 동참할 것인가 말 것인가? (Med Teach, 2016)

Meded. 2018. 6. 15. 21:53

2018. 6. 15. 21:53

프로페셔널하지 못한 행동에 동참할 것인가 말 것인가? (Med Teach, 2016)

To participate or not participate in unprofessional behavior – Is that the question?

Renato Soleiman Francoa,b , Camila Ament Giuliani dos Santos Francoa,b , Solena Ziemer Kusmaa ,

Milton Severob and Maria Amelia Ferreirab,c

aMedicine School, Pontifical Catholic University of Parana, Curitiba, Brazil; bDepartment of Medical Education and Simulation, Faculty of Medicine, University of Porto, Porto, Portugal; cFaculty of Medicine, University of Porto, Porto, Portugal

도입

Introduction

비전문가적 행동은 프로페셔널리즘을 위반한 것으로, 징계 조치를 받을 가능성이 있다 (Papadakis 외 2004, Teherani 외 2005). 학업 부정 행위에 연루된 대부분의 의대생이 자신의 위반에 대해 징계를받지는 않지만, 학생 시기의 위법 행위misconduct는 훗날 전문직 커리어에서 징계를 받는 것의 위험 요소입니다 (Yates & James 2010).

Unprofessional behavior relates to a violation of professionalism for which one has an increased chance of incurring disciplinary action (Papadakis et al. 2004; Teherani et al. 2005). Even though most medical students involved in academic misconduct will not be disciplined for their infractions, misconduct as a student is a risk factor for disciplinary problems in one’s professional career (Yates & James 2010).

전문직 및 비전문가적 행동은 많은 접근법과 방법을 사용하여 연구되었습니다. 시카고 대학의 Pritzker School of Pritzker School은 일련의 행동 양식을 열거하고 학생들에게 그들이 프로페셔널이 아닌지 관찰하고 참여했는지 여부를 묻습니다 (Humphrey 외 2007, Reddy 외 2007). 이 설문지는 다른 연구자에 의해서도 적용된 바 있다 (Reddy 외 2007, Humphrey 외 2007, Arora 외 2008, Arora 외 2010, Dyrbye 외 2010, Byszewski 외. 2012; Reddy et al., 2012; Kulac et al., 2013).

Professional and unprofessional behaviors have been The studied using many approaches and methods. University of Chicago Pritzker School of Medicine listed a set of behaviors and asked students if they had observed, participated in and judged them to be unprofessional (Humphrey et al. 2007; Reddy et al. 2007). This questionnaire has been adapted and applied in different contexts and countries by other researchers (Reddy et al. 2007; Humphrey et al. 2007; Arora et al. 2008; Arora et al. 2010; Dyrbye et al. 2010; Byszewski et al. 2012; Reddy et al. 2012; Kulac et al. 2013).

학부 수준에서 시작하여 의대생은 다양한 학습 기회를 제공받으며, 다양한 잠재적 역할 모델에 노출되어 있으며, 그 중 일부는 긍정적, 전문적 행동보다 부정적 행동을 모델링 할 수 있습니다 (Hendelman & Byszewski 2014). 롤모델은 전문성 교육을 지원하는 주요 전략 중 하나로 추진되어왔다 (Birden et al., 2013).

Beginning at the undergraduate level, medical students are immersed in diverse learning opportunities and are exposed to a variety of potential role models, some of whom could model negative behaviors more often than positive, professional behaviors (Hendelman & Byszewski 2014). Role models have been promoted as among the main strategies to support the teaching of professionalism (Birden et al. 2013),

어떤 행동을 자주 보게 되면 그 행동이 허용된다고 생각하게 될 수 있으며, 학생들은 일부 레지던트와 주치의가 이러한 행동에 관여하는 순간 뿐만 아니라, 다른 사람들의 위법 행위를 교정해주지 않는 것을 보면서도 시작될 수 있다(Wear et al., 2006; Bryden et al 2010).

Frequent observation could promote a sense that a given behavior is permissible, and may begin when students see that some residents and attendants are not only involved in these behaviors, but also refrain from correcting misconduct in others (Wear et al. 2006; Bryden et al. 2010).

다양한 이론이 행동을 이끌어내는 요인을 설명 할 수 있으며, 가장 일반적으로 사용되는 이론 중 하나는 계획된 행동 이론 (TBP)입니다. 전통적으로 TPB는 태도와 주관적 규범에 의해 결정되는 행동 수행의 가장 결정적인 요소 중 하나 인 의도적 행동 이론(TRA)의 확장으로 이해 될 수있다 (Conner & Armitage 1998). 비록 의도가 광범위한 행동을 설명해주긴 하나, 복잡한 행동, 특히 퍼포먼스와 밀접한 관련이 있는 행동은 다른 변수의 영향을받는 것으로 보입니다. 따라서, TPB는 행동 통제 (PBC)를 TRA에 통합시켰다 (Conner & Armitage 1998; Sheeran et al., 2003). PBC는 자신의 효율성과 특정 행동에 관여하는 능력에 대한 자신의 평가를 나타냅니다.

Different theories could explain what drives behavior, and one of the most commonly used and accepted is the theory of planned behavior (TBP). Classically, the TPB can be understood as an extension of the theory of reasoned action (TRA), in that intention is one of the closest determinants of the performance of a behavior which, in turn, is determined by attitude and subjective norms (Conner & Armitage 1998). Although intention explains a wide range of behaviors, more complex behavior, especially that which is closely related to performance, seems to be influenced by other variables. Thus, the TPB incorporated perceived behavioral control (PBC) into TRA (Conner & Armitage 1998; Sheeran et al. 2003). PBC refers to one’s assessment of one’s own efficiency and ability to engage in certain behaviors.

방법

Methods

표본과 자료 수집

Sample population and data collection

The unprofessional behavior survey was based on two studies carried out at the University of Chicago Pritzker School of Medicine (Humphrey et al. 2007; Reddy et al. 2007), which listed a set of behaviors and asked medical students if they had observed and participated in these behaviors, and whether they judged them to be unprofessional.

We built a survey that listed 22 behaviors; its face validity was assessed by two medical educators from each university in this study. Both schools are in Portuguese-speaking countries, although there are many differences in usage and idiom between Brazil and Portugal.

The medical educators involved were fluent in English grammar, so they were able to assess whether the behaviors translated into Portuguese had the same meanings in Portugal and in Brazil.
They described the meaning of each behavior and ensured that they were referred to the same specific aspects.
They out carried this evaluation independently first, and then in a consensus meeting.
After that, they did a pre-test study of the questionnaire with a group of five students in each country in order to assess if all questions were understood by the students.

For each behavior, we designed three questions,

asking students whether they had observed the behavior (yes/no),
whether they had participated in the behavior (yes/no), and
how they had judged the behavior (unprofessional, borderline or professional).

Thus, the survey comprised a total of 66 questions in three domains: observation, participation, and judgment.

The original Pritzker questionnaire asked if the students had judged each behavior as professional or unprofessional. We inserted the intermediary classification of “borderline” into this field. Thus, the possibilities for the student’s judgment of the behavior were unprofessional, borderline, and professional.

자료 분석

Data analysis

Confirmatory factor analysis was used to assess the three domains in our theoretical framework: observation, participation in and judgment of unprofessional behaviors, with residual correlations between each behavior.

결과

Results

We tested the model with three factors: observation, participation, and judgment, as well as with the residual correlation within each behavior observed, participated in, and judged (Table 2). Almost all items showed a high factor loading with the respective domain.

Thus, we could analyze data assessing not only each behavior but also the domain as a whole (Table 2).

각 행동에 대한 빈도

The frequencies related to each behavior are presented in Table 3, displayed in the three categories of academic,clinical, and patient-related. Most of the responses regard-ing behaviors displayed no statistical differences between UNIPT and UNIBR students.

관찰-참여, 참여-판단 사이에 유의한 상관관계. 관찰과 판단 사이에는 유의했지만, 강도는 낮음

Among both sample populations, there were strong and significant correlations between observation and participation (r ¼0.54, p<0.001) and between participation and judgment (r ¼0.44, p<0.001). The correlation between observation and judgment was significant but less strong (r ¼0.26, p<0.001).

After adjusting for curricular year, country, and gender, the observation and judgment scores were positively associated with the participation score (Table 4).

고찰

Discussion

이 연구의 주요 결과는 다음과 같이 나타냅니다.

(1) unprofessional하다고 느끼거나 가장 동참하지 않을 행동은 환자와 직접적인 관련이있는 행동이었습니다.
(2) 관찰과 참여 사이, 참여와 판단 사이의 연관성이 유의미했다.
(3) 학생의 unprofessional한 행동에 대한 동참은 행동의 관찰, 행동에 대한 그들의 판단, 학년에 따라 다르다
(4) 상관 관계와 연관성에도 불구하고, 어떤 행동을 'professional'하다고 잘 못 판단할 가능성보다 그 행동에 동참할 가능성이 더 높았다.

The main findings of the study indicate:

(1) the behaviors that students were most likely to consider unprofessional and in which they were least likely to participate were those directly related to patients;
(2) the associations between observation and participation and between participation and judgment were both significant;
(3) the students’ participation in unprofessional behavior could be driven by their observation of the behavior, their judgment of the behavior and their academic year;
(4) despite the correlations and associations, participation was higher than the prevalence of misjudgment of an action as professional.

교육적(또는 비교육적) 환경이 있는가?

Are there educational or (un)educational environments?

관찰 된 unprofessional 행동의 평균은 양국 모두에서 높았고, 학업적 부정 행위에 대한 관찰이 특히 prevalent했다. 유사성에도 불구하고 두 샘플간에 통계적으로 유의미한 차이를 보인 행동도 있었다. 여기에는 주로 시험에서 부정 행위를 관찰한 것이나, 다른 학생으로 서명하는 등 학업 환경에서의 행동과 관련하여 발생한 것으로 UNIBR에서 더 높았다.

The mean of observed unprofessional behavior was high in both countries, and the observation of academic misconduct was especially prevalent. Despite the similarities, there were behaviors that showed statistically significant differences between the two samples. This occurred primarily in relation to behaviors in the academic setting, such as observing cheating on exams and signing as another student, which were higher at UNIBR,

부정 행위에 대한 관찰은 학업 상황에만 국한된 것이 아니며, 응답자의 절반 이상이 환자 치료와 관련된 행동의 65 %를 관찰하엿다고 응답했다.

The observation of misconduct was not restricted to the academic setting, and 65% of behaviors related to patient care had been observed by more than 50% of respondents.

비록 롤모델의 사용은 결정적으로 중요하지만, 의사 소통 교육은 롤모델에만 의존하기보다는 정식 (교과) 교육 프로그램, 비판적 사고의 개발, 직장 학습, 모의 훈련, 피드백,보고 및 이론적 지식과 같은 여러 가지 전략을 필요로합니다. (Feraco et al., 2016). 따라서 의사 소통에 있어서 poor conduct를 하는 경우에 그것이 학생에게 어떤 메시지를 보내는지를 고려하는 것이 중요하며, 이로써 distant and ineffective 의사-환자 관계 유발을 피할 수 있다.

The teaching of communication needs to strategies, include multiple such as formal (curricular) teaching programs, development of critical thinking, workplace learning, simulated training, feedback, debriefing and even theoretical knowledge, rather than relying solely on the use of role models; although the use of role models remains crucially important (Feraco et al. 2016). Thus, it is important to consider the types of messages sent to students in such instances of poor conduct in communication, in order to avoid bringing about a distant and ineffective doctor–patient relationship.

적절한 자기 밝힘self-presentation은 정직하고 정중한 의사 소통 과정에서 시작되며, 의사와 환자 간의 초기 관계에서 중요한 역할을합니다 (King & Hoppe 2013). 두 대학 모두 학생들은 동료가 자신을 의사라고 잘못 present하거나, 스스로 의사로 오인받는 것을 시정하지 않는 상황을 관찰했다. 또한 응답자의 약 20 %가 이러한 행동에 직접 참여했다.

Adequate self-presentation begins with an honest and respectful communication process and serves as an important part of the initial rapport between doctor and patient (King & Hoppe 2013). In both universities, students reported observing situations in which classmates falsely presented themselves as doctors or failed to correct someone who mistook them for doctors. Moreover, around 20% of respondents had participated in such behaviors themselves,

이 유형의 행동에 대한 동참 또는 잘못된 판단은 임상실습 기간동안 증가할 수 있으며, 이는 임상 상황 자체가 위험한 습관을 심어줄 수 있음을 보여준다(Hicks 외 2005, Reddy 외 2007, Kulac 외 2013).

The participation in and misjudgment of this type of behavior may increase during clerkship (Hicks et al. 2005; Reddy et al. 2007; Kulac et al. 2013), revealing that the clinical setting itself could instill some dangerous habits.

무엇이 학생들이 프로페셔널하지 못한 행동에 대한 오판과 동참으로 이끄나?

What makes students more prone to misjudging and participating in unprofessional behavior?

관찰과 참여 사이의 연관성은 유의하고 강했다 (0.54). 이 결과는 예상할 수 있었는데, 다른 사람들로부터 어떤 행동을 전혀 관찰하지 않고서 그 행동에 참여하는 것은 어렵기 때문이다.

The association between observation and participation was significant and strong (0.54). This result could even be expected, as it would be difficult to be involved in behavior without first having observed it in others.

그러나 이 숫자의 중요성을 고려한다면, 환경을 조사해야합니다. 학생들은 어떤 행동을 관찰했을 때, 그것이 주어진 그룹에서 기대되는 것으로 또는 적어도 받아 들일 수있는 것을 반영한다고 인식 할 수 있습니다. 이것은 이런 종류의 행동에 함축된 주관적인 규범을 드러 낼 수 있습니다.

However, given the importance of these numbers, one must look into the environment. Students could perceive the behaviors they observe to be reflections of what is expected or, at least, tolerable in the given group. This could reveal some subjective norms that are implicit in this kind of behavior.

따라서 비록 이것이 예상되는 상관 관계이긴하지만, 행동의 관찰을 통해 행동에 참여하겠다는 의지를 표명 할 때, 참여(동참)는 TPB의 주관적인 규범과 관련 될 수있다. 이런 식으로 관측은 행동을 시작하거나 유지하기위한 출발점이 될 수 있습니다.

Thus, even though this is an expected correlation, with the observation of behavior opening one’s willingness to engage in that behavior, participation could also be related to the subjective norms of the TPB. In this way, observation could be a starting point to initiate or maintain a behavior.

다양한 학습 상황에서, 의대생은 부정 및 긍정적 행동 모델 (Hendelman & Byszewski 2014)과 같은 다양한 사례에 노출 될 것입니다.

In diverse learning situations, medical students will be exposed to a variety of examples, including negative and positive models of behavior (Hendelman & Byszewski 2014).

의도적 행동의 관찰에서 그 행동에 참여하기까지 이르는 과정은 (충동적 또는 비자발적 행위의 경우를 제외하면) 그 이유가 무엇인지를 검토하는 과정을 밟는다scrutiny. 프로페셔널리즘이 결여된 것을 관찰하더라도, 학생들은 그들이 본 행동을 판단할 기회를 갖게 되며, 많은 학생들은 그 행동을 따라하지 않는다.

The pathway from the observation of an intentional behavior to participation in that behavior must undergo the scrutiny of reason, except in the case of impulsive or involuntary acts. After a lack of professionalism is observed, students have the opportunity to judge the modeled behaviors, and go on many will not to participate.

비전문적, 경계선, 전문적 행동에 대한 학생의 판단은 행동에 대한 태도와 동등한 것으로 간주되어야합니다. 판단은 참여와 유의미한 상관 관계가 있었기 때문이다.

The student’s judgment of the behavior as unprofessional, borderline, or professional should be considered equivalent to his or her attitude toward the behavior. Judgment was significantly correlated with participation,

비전문적 행동에 대한 학생의 동참여부는 행동을 관찰했는지 여부, 그 행동에 대한 판단, 학년에 의해 45 % 설명되었습니다.

Students’ participation in unprofessional behavior was 45% explained by the respondents’ observation of the behavior, judgment of the behavior, and academic year.

관찰, 참여, 판단 사이에는 상당한 상관 관계가 있습니다. unprofessional한 행동을 관찰하거나 참여한 학생은 악순환에 빠진 것처럼 보였습니다. 일단 학생이 어떤 유형의 unprofessional한 행동을 관찰했거나, 동참했거나, 잘못된 판단을 내리면 미래에 다시 그렇게 할 가능성이 높아졌습니다. 한 번 참여하기 시작하면 바람직하지 못한 관행이 유지 될 수 있으므로 이로 인해 불행한 결과가 초래 될 수 있습니다(Benbassat 2014) .

Observation, participation, and judgment have considerable correlations amongst themselves. The student who observed or participated in unprofessional behavior seemed to enter into a vicious circle: once the student had observed, participated in or misjudged a certain form of unprofessional behavior, the likelihood that he/she would do so again in the future increased. This could bring about unfortunate consequences, as once one begins to participate, it is possible that the undesirable practices will be maintained (Benbassat 2014).

따라서 우리는 어느 시점에서, 환경의 주관적인 규범이 전문적이지 않은 행동을 암묵적으로 지지한다고 인식하는 학생들을 만날 수 있습니다. 그들은 이러한 방식으로 이러한 행동에 대한 개입이 정당하다고 믿게되었을 것입니다. 일부 학생들은 판단력이 부족하고, 어떤 형태의 승인을 받은 결과로서, unprofessional한 행동을 하기로 결정했을 수도 있습니다.

Thus, we may have come across students who at some point perceived that the subjective norms of their environment had tacitly endorsed unprofessional behaviors; they may have, in this way, come to believe that their engagement in these behaviors was justified. It is also possible that some students were lacking judgment and, having received some form of authorization, decided to engage in unprofessional acts.

두 경우 모두, 의도와 주관적 규범은 인지 조화가 행동의 중심에 놓이는 과정의 일부임을 알 수 있습니다. Unprofessional한 행동에 대한 동참 원인을 보면 판단, 참여, 관찰의 조화를 보여준다. 그러나 일부 학생은, 그 행동이 unprofessional 하거나 borderline으로 판단하였음에도 행동에 참여했습니다. 이처럼 규범과 개인적 신념 사이의 불일치가 있을 때, 인지 부조화가 발생한다 (Wald et al. 2012).

In both cases, one may notice that intention and subjective norms are part of a process in which cognitive consonance lies at the center of behavior. The correlations and the percentage of explained participation showed consonance aligning judgment, participation, and observation. However, some of the students who judged a behavior to be unprofessional or borderline were participating in that behavior. When there is conflict in cognition, for example in disagreements between norms and personal beliefs, cognitive dissonance takes place (Wald et al. 2012).

어떤 행동을 하면서도, 그것이 unprofessional하다고 판단하는 학생 (또는 경계선이라고 판단하는 학생) 역시 도덕적 원칙에 반하여 그러한 행동을 하는 것이고, 자신의 행동에 대한 인지부조화가 나타납니다. 이러한 내부 갈등과 관련된 상황에서, 많은 학생들이 인지적 조화가 dictate하는 과정을 깸으로써 도덕적 스트레스를 받는다고 느낍니다.

Students who participate in behaviors but judge them to be unprofessional (or even those who judge them to be borderline) could have done so against their moral principles, thus displaying cognitive dissonance in their actions. In situations involving these internal conflicts, many students feel compelled by moral distress, breaking the process dictated by cognitive consonance.

부정적인 역할 모델링은 학생들에게 높은 비율로 도덕적 스트레스를 유발하며, 원칙에 어긋난 행동을 하게 유도한다(Lomis 외. 2009). 또한 스트레스가 많은 상황에서는, 유연한 기억flexible memory을 "습관"으로 굳어지게 만들기도 한다(Schwabe & Wolf 2013).

Negative role modeling has been correlated with higher rates of students’ moral distress and inducement to act against their principles (Lomis et al. 2009). In addition,stressful situations may lead a flexible memory to become a rigid “habit” (Schwabe & Wolf 2013).

판단의 분야에서, 우리는 약 3 가지 카테고리 (전문가가 아닌, 경계선, 직업)를 물었다. 학생이 비전문적 행동을 전문적 행동으로 잘못 판단하는 경향은, borderline이라는 믿음으로 시작될 수 있습니다. 경계선 응답은 그 행동이 전문적인지 아닌지에 대해서 불확실하다는 것을 의미할 수도 있고, 또는 그 행동이 완전히 전문적인것도 완전히 비전문적인것도 아니라고 생각한다는 것을 의미 할 수 있습니다. 이것은 학생들이 자신의 행동이나 신념을 의심 할 수 있음을 시사합니다.

In the field of judgment, we asked about three categories (unprofessional, borderline ,and professional). It is possible that a student’s inclination to misjudge an action as professional can begin with the belief that it is borderline. The borderline answers could mean uncertainty about whether a behavior is unprofessional, or they could mean that the students consider the behavior to be neither totally professional nor unprofessional. This suggests that students may doubt their own behaviors or beliefs.

따라서 판단 점수에 근거한 비전문가 행동에 참여하는 경향은 "의심을 던지는 학생"에 근거하고 있어야합니다.

Thus, the tendency to participate in unprofessional behavior based on the judgment score should be grounded by students in doubt.

우리의 데이터를 다른 연구와 비교하면 프로답지 않은 것으로 판단되는 행동에 약간의 차이가 있음을 알 수 있습니다. 그러나 우리가 전문적인 것으로 판단되는 행동 유형을 고려할 때 큰 차이가있었습니다. 예를 들어, Reddy 외 (2007)의 연구에서, 전임상 학생의 19 %와 임상실습 중 학생의 27 %는 misjudged action을 professional하다고 보았다. 반면, 이번 연구에서는 학생의 1 %만이 misjudged actions을 프로페셔널하다고 보았다.

Comparing our data with other studies , one finds little difference in some of the behaviors judged to be unprofessional . However,there were large differences when we considered the types of behaviors judged to be professional. For example, in Reddy et al.’s(2007) study, which considered students both pre- and post-clerkship, 19% of pre-clerkship students and 27% of students in their clerkship misjudged actions as professional. In our study, only 1% of students misjudged actions as professional.

이 발견은 훌륭한 역할 모델을 제공하고, 잘못된 행동을 교정하며, 의학 교육의 시작과 평생 학습을 통한 전문성에 대한 성찰의 중요성을 강조합니다. 그러한 조치가없는 경우, 이러한 행동은 학부 수준을 넘어서고 학생의 미래 전문 직업에 영향을 줄 수 있습니다 (Fargen 외 2016). 이러한 문제를 효과적으로 해결하기 위해 교수 전략은

These findings highlight the importance of providing good role models, remedying misconduct, and reflecting on professionalism from the very beginning of medical education and throughout lifelong learning. In the absence of such measures, these behaviors could continue past the undergraduate level and affect the student’s future professional practice (Fargen et al. 2016). In order to address these issues effectively, teaching strategies should

(1) 부정적인 역할 모델링에 대한 비판적인 평가를 수행한다.
(2) 학생들의 지식 및 윤리적 및 분석적 기술의 결함을 개선한다 (Berger 2014).
(3) 역할 모델 활용과 학생 행동의 평가(형성 및 총괄)의 단점을 개선한다 (Byszewski et al., 2012);
(4) 학생들이 전문성에 대한 그들의 헌신을 강화하고, 인지 부조화를 줄이도록 empower한다(Amoura 외 2015).

(1) undertake a critical appraisal of negative role modeling;
(2) remedy deficiencies in students’ knowledge and ethical and analytical skills (Berger 2014);
(3) remedy deficiencies in the use of role models and in the assessment (formative and summative) of students’ behaviors (Byszewski et al. 2012); and
(4) empower students to enhance their commitment to professionalism and reduce cognitive dissonance (Amoura et al. 2015).

이러한 조치는 학생들의 전문적인 행동에 대한 이해와 기대를 높이고 개인 신념, 직업적 규범 및 직장 관행 탐색의 복잡성을 효과적으로 처리하도록 도울 수 있습니다.

Such measures may enhance students’ understanding and expectations about professional behavior and help them deal effectively with the complexity of navigating personal beliefs, professional norms, and workplace practices.

결론

Conclusions

비전문가 행동에 참여하는 주제는 다각적이며 간-학제적입니다. 따라서 교수진이 이러한 상황을 적절하게 처리하려면 다양한 요인을 고려해야합니다.

학습 환경 ( "숨겨진"및 "공식"커리큘럼 포함)은 전문적 또는 비전문적 행동의 예를 풍부하게 제공하며, 이 모든 것은 학습의 가능성을 나타냅니다.
비판적 사고의 촉진은 학생들이 전문직 정체성을 구축 할 때 학생들에게 긍정적 인 영향을 미쳐야하는 건전한 전략이며 (Langendyk et al., 2016), 이는 미래의 임상에서의 양심적인 행동으로 이어질 것입니다.

The subject of participation in unprofessional behavior is multifaceted and interdisciplinary. Thus, in order for faculty members to adequately handle these situations, they have to consider the variety of factors involved.

The learning environment (including the “hidden” and “formal” curricula) provides an abundance of examples of unprofessional (and professional) behavior, all of which represent possibilities for learning.
The promotion of critical thinking is a sound strategy that should positively impact students as they build their professional identities (Langendyk et al. 2016), and this should lead to more conscientious behavior in future clinical practice.

전문가가 아닌 행동을 치료하는 전략을 개발하는 것을 무시하면 악순환이 생길 수 있습니다. 이것을 확인하지 않으면, 복잡성이 증가하고 해결하기가 어려워집니다. 만약 관찰과 참여와 잘못된 판단이 서로 영향을주고, 스스로에게 feed upon할 수 있따면, 반대로 비판적 사고와 행동의 올바른 판단이 바깥으로도 퍼져나가 프로페셔널 한 문화를 육성 할 수도 있습니다.

Neglecting to develop strategies to remedy unprofessional behavior could lead to a vicious circle that, if unchecked, will only grow in complexity and become more difficult to resolve. If it is possible that observation, participation, and poor judgment influence each other and feed upon themselves, then it also seems possible that higher degrees of critical thinking and good judgment in behavior could ripple outwards and forwards as well, fostering a culture of professionalism.

이러한 데이터를 토대로 unprofessional한 행동에 참여하거나, 어떤 unprofessional한 행동을 professional한 것으로 인식하는 학생에 대해서 더 또는 덜 unprofessional하다고 판단내리는 것은 실수입니다. 우리의 목적은 unprofessional한 행동에 대한 복잡한 관점을 유지하는 것이 중요하다는 점을 밝히고 "잘못된 행동"을 찾아 내고 전문가, 학생, 환자, 사회를 위한 보다 나은 건강 관리 시스템 및 의학 교육 프로그램을 지원하는 것입니다.

It would be a mistake to declare that, based on these data, the students who participated in one unprofessional behavior and/or perceived a certain unprofessional behavior to be professional were more or less professional than other who did not. Our purpose is to shed light on the importance of maintaining a complex and multifaceted not view of unprofessional behaviors, to find a “wrongdoer”, but rather to support a better health care system and medical education programs for professionals, students, patients, and society at large.

Limitations

Hendelman W, Byszewski A. 2014. Formation of medical student professional identity: categorizing lapses of professionalism, and the learning environment. BMC Med Educ. 14:139. Available from: http://bmcmededuc.biomedcentral.com/articles/10.1186/1472-692014-139.

Benbassat J. 2014. Role modeling in medical education. Acad Med. 89:550–554. Available from: http://www.ncbi.nlm.nih.gov/pubmed/ 24556777.

Med Teach. 2017 Feb;39(2):212-219. doi: 10.1080/0142159X.2017.1266316. Epub 2016 Dec 26.

To participate or not participate in unprofessional behavior - Is that the question?

Franco RS1,2, Franco CA1,2, Kusma SZ1, Severo M2, Ferreira MA2,3.

Author information

1: a Medicine School, Pontifical Catholic University of Paraná , Curitiba , Brazil.
2: b Department of Medical Education and Simulation, Faculty of Medicine , University of Porto , Porto , Portugal.
3: c Faculty of Medicine , University of Porto , Porto , Portugal.

Abstract

INTRODUCTION:

Medical education provides students with abundant learning opportunities, each of which is embodied with messages concerning what is expected from students. This paper analyses students? exposure to instances of unprofessional behavior, investigating whether they judge such behavior to be unprofessional and whether they also participate in unprofessional behavior.

METHODS:

The survey developed in the Pritzker School of Medicine at the University of Chicago was the basis of this questionnaire that was answered by 276 students from two medical schools in Brazil and Portugal.

RESULTS:

Unprofessional behavior was observed frequently by students in both universities, and the mean participation rates were similar (26% and 27%). Forty-five percent of students? participation in unprofessional behavior was explained by academic year, prior observation, and judgment.

DISCUSSION:

The results indicate that once students have observed, participated in or misjudged unprofessional behavior, they tend to participate in and misjudge such behavior. The frequency with which students judged behaviors they had observed or participated in as ?borderline? or unprofessional could mean that they are experiencing moral distress.

CONCLUSION:

Proper discussion of unprofessional behavior should foster a broad debate to encourage empowered students, faculties, and physicians to co-create a more professional environment for patient care.

PMID:: 28024438
DOI:: 10.1080/0142159X.2017.1266316

저작자표시 비영리 변경금지

'Articles (Medical Education) > 전문직업성(Professionalism)' 카테고리의 다른 글

인본주의적, 회복탄력적 의사 양성을 위한 전문직 정체성 형성: 이론을 실제와 연결시키기 위한 교육전략(Acad Med, 2015) (0)	2018.06.20
불확실성에 대한 내성 측정: 1학년부터 6학년까지 단면연구(BMC Family Practice, 2014) (0)	2018.06.20
의과대학 초기에 전문직정체성 측정하기(Med Teach, 2016) (0)	2018.06.15
헬스케어와 교육에서 비판적 사고(BMJ, 2017) (0)	2018.06.13
의과대학생의 정체성 형성: 의학교육의 교육적 과제(Teach Learn Med, 2013) (0)	2018.06.10

의과대학 초기에 전문직정체성 측정하기(Med Teach, 2016)

Meded. 2018. 6. 15. 21:40

2018. 6. 15. 21:40

의과대학 초기에 전문직정체성 측정하기(Med Teach, 2016)

Measuring professional identity formation early in medical school

Adina Kaleta, Lynn Buckvar-Keltza, Victoria Harnikb, Verna Monsonc, Steven Hubbardb, Ruth Crowea,

Hyuksoon S. Songd and Sandra Yinglingb,e

aDivision of General Internal Medicine and Clinical Innovation, New York University School of Medicine, New York, NY, USA; bNew York University School of Medicine, New York, NY, USA; cMonson Consulting and Evaluation, Minneapolis, MN, USA; dDepartment of Education, Georgian Court University, Lakewood, NJ, USA; eDepartment of Medical Education, University of Illinois College of Medicine, Chicago, IL, USA

도입

Introduction

의료 전문 직업적 정체성은 "의료 직업의 특성, 가치 및 규범이 내면화되는 시간이 지남에 따라 단계적으로 달성 된 자아의 표현"으로 정의되었다 (Cruess et al., 2014). 전문직 정체성 형성 (PIF)은 발달적 구조로서 신뢰성있고 의미있게 측정 될 수 있으며, 우리는 그 발달에 기여하는 것을 더 잘 연구 할 수 있을 뿐만 아니라, 의학 프로페셔널리즘에 대한 훈련생의 숙달을 명시적으로 지원하는 방법을 이해할 수있을 것입니다.

medical professional identity has been defined as a “… representation of self, achieved in stages over time during which the characteristics, values, and norms of the medical profession are internalized” (Cruess et al. 2014). If professional identity formation (PIF) can be reliably and meaningfully measured as a developmental construct, we will be better able to study what contributes to that development as well as understand how to explicitly support trainees’ mastery towards medical professionalism.

의대생은 의사가 되어간다. 여러 다른 정체성과 더불어서, 직업적 정체성을 형성하는 방식은 현재와 미래의 웰빙과 관계에 중요합니다 (Monrouxe 2010). 이것은 모두 역동적인 개인적, 복잡한 대인관계 및 사회문화적, 고도로 주관적인 발달 과정입니다.

Medical students are becoming physicians. The ways in which they form their professional identity along with multiple other identities matters to their present and future well-being and relationships (Monrouxe 2010). This is both, a dynamic personal as well as a complex interpersonal and socio-cultural, highly subjective developmental process.

일부 이론가들은, 초기 성인에게 있어서, PIF는 대체로 의과대학 지원과정에서 강화 된 외부적으로 정의된 과정이며, 이 과정은 대단히 경쟁이 심하고, 개인의 성취를 중시하는 과정이다. 그 결과 이 초기 성인기의 지원자들은 "외부에서 정의되고 개인에게 집중되는 업적"을 강조하는 전문직에 들어서는 압력을 받게 되는 것입니다. 의학교육자들은 이 학생들을 PIF와 도덕적 추론의 초기 단계에서 효과적이면서 이타주의적인 의사, 사회적 정의를 지향하는 의사라는 상위단계로 안내하는 중요한 임무를 수행합니다 (Jarvis-Selinger 외. 2012).

Some theorists posit that early on, in young adults, PIF is a largely externally defined process reinforced in the application process to medical school, which is highly competitive and emphasizes personal achievement. This pressures young adults seeking entr ee into the profession to focus on achievements that are externally defined and individually focused. Medical educators have the important task of guiding these students from early stages in PIF and moral reasoning toward the advanced stages needed to become effective, altruistic physicians, and social justice oriented (Jarvis-Selinger et al. 2012).

최근 강조되는 PIF는 프로페셔널리즘 교육은 학생들이 종종 깊은 생각과 헌신없이 생성하는 "가치와 행동 목록"으로 구성된 피상적 노력으로 간주될 수 있다는 우려를 제기합니다 (Wynia 외 2014). 강건하고 회복탄력적인 의료 전문직 정체성 (Goldie 2012, Holden et al 2015)의 발전을 장려하기 위해 부유하고, 종단적이고, 다중적 방식의 교육 과정이 시행되고 있지만, 벤치 마크 측정은 아직 이용 가능하지 않다.

The recent focus on PIF addresses the concern that professionalism education often has been seen as a superficial effort consisting of “lists of values and behaviors” that can be generated by students with insufficient depth of thought and commitment (Wynia et al. 2014). Rich, longitudinal, multi-method curricula are being implemented to encourage the development of a hardy, resilient medical professional identity (Goldie 2012; Holden et al. 2015), but benchmark measures are not yet available.

의학 및 기타 전문 학교에서 PIF를 강조하는 움직임은 부분적으로는 "아는 것"과 "하는 것"의 gap을 연구 한 도덕 심리학자 연구에서 유래합니다. 개인이 직업의 가치에 따라 행동해야 한다는 강한 믿음을 가질 수는 있지만, 그 신념이 자신의 정체성에 깊이 뿌리 내리지 않은 경우, 이것만으로 행동을 보장하기에는 불충분합니다 (Blasi 1980, 2004). 우리는 시간에 걸쳐 변화하는 PIF를 측정하려고했기 때문에, '정체성 발달'이란 의과대학 입학하기 전부터 시작되어 그 이후로 전문직 생에에 결처 진행되는 인지적, 사회적, 감정적인 능력을 통합하는 평생의 과정이라고 제안한 건설적 발달 이론가인 로버트 케간 (Robert Kegan)의 연구에서 비롯된 프레임 워크를 선택했습니다 (Kegan 1982; Bebeau 2006).

The movement to emphasize PIF in medical and other professional schools stems in part from the work of moral psychologists who studied the gap between “knowing and doing,” noting that the individuals may profess strong beliefs in acting according to the values of a profession, but beliefs alone are insufficient to ensure behaviors if they are not deeply rooted in one’s identity (Blasi 1980, 2004). Because we were seeking to measure PIF over time, we have chosen a framework stemming from the work of constructive developmental theorist Robert Kegan, who proposed that identity development is a life long and process of integrating cognitive, social, emotional capacities which begins before entering professional school and continues throughout professional life (Kegan 1982; Bebeau 2006).

직업적 정체성 에세이 (PIE)는 사회에서의 전문직 역할에 대한 개념화를 도출하고 전문직 교육 (표 1 참조) (Kegan 1982)에서 사용하기에 적합한 Kegan 이론의 단계를 측정합니다. 학생들은 고도로 숙련 된 전문가가 전체 문서에 Kegan 무대 점수를 할당하는 기초가되는 7 가지 프롬프트 (표 2)에 대한 간단한 서술 응답을 작성합니다.

The professional identity essay (PIE) elicits a respondent’s conceptualization of a professional role in society and measures the stages of Kegan’s theory adapted for use in professional education (See Table 1) (Kegan 1982). Students write brief narrative responses to seven prompts (Table 2), which are the basis for assigning an overall Kegan stage score to that document by a highly trained expert.

치과대학 학생 정체성 에세이의 내용 분석에서 Monson, Roehrich 및 Bebeau는 3-4 단계 (코호트의 37 %를 대표하는)의 치과대학생이 의료의 격차를 줄이고, 의료가 필요한 사람을 위해 봉사할 것이라고 기술했기 때문에, 학생들을 보다 복잡한 정체성 단계로의 성장할 수 있도록 촉진하는 것이 중요함을 지지하였다(Monson et al., 2008).

In a content analysis of dental student identity essays, Monson, Roehrich, and Bebeau found that dental students at stage 3–4 (representing 37 percent of a cohort) were more likely to state that they expected to make a contribution to society in reducing healthcare disparities, serving medical assistance patients, and volunteering to help those in need, supporting the importance of promoting growth towards more complex stages of identity (Monson et al. 2008).

Table 1. Kegan stages: the four broad levels of mental complexity relevant for professional education.

Table 2. The PIE instructions and prompts (modified for use in medicine).

도덕적 추론

Moral reasoning

의학에서의 도덕적 딜레마에는 대개 단 하나의 정답만 있는 것이 아니다. 성숙한 전문가들은 개인적 관심사라든가, 좁게 정의된 규칙보다는, 윤리적 또는 전문적 원칙에 기초하여 그러한 딜레마에 대처하는 경향이있다 (Rest 1986, 1994; Beauchamp & Childress 2001). 우려되는 것은 medical training이 도덕적 딜레마에 대한 감수성을 무디게하고 도덕적으로 성장할 것으로 예상되는 나이와 교육 추론을 늦추는 것이다 (Self et al., 1993; Patenaude et al., 2003; Bebeau & Faber-Langendoen 2014; Murrell 2014).

Moral dilemmas in medicine typically do not have a single right answer. Mature professionals tend to respond to such dilemmas based on ethical or professional principles, rather than personal interest or narrowly defined rules (Rest 1986, 1994; Beauchamp & Childress 2001). Of concern is that medical training blunts sensitivity to moral dilemmas and slows the expected age and education reasoning based growth in moral (Self et al. 1993; Patenaude et al. 2003; Bebeau & Faber-Langendoen 2014; Murrell 2014).

이슈 정의 테스트 (DIT2)는 도덕적 문제에 직면할 때 개인이 설득력있는 것으로 보이는 도덕적 논증의 유형을 측정하는 것으로, 도덕적 판단의 척도이다. 그러나 이는 도덕적 행동에 필수적이지만 충분하지는 않습니다 (Bebeau 2002).

The defining issues test (DIT2) measures the types of moral arguments an individual finds persuasive when confronted with a moral problem and therefore is a measure of moral judgment – a necessary but not sufficient component of moral behavior (Bebeau 2002).

행동에 대한 정당화는 세 가지 일반적인 도덕적 스키마로 묶이는 경향이 있습니다.

개인의 이익을 보호하고 (PI),
규칙과 규범을 지키고 (MN),
보편적인 윤리적 원칙을 적용하는 것(흔히 "포스트 관습적 사고"라고 불리며 N2 점수로 측정 됨)

Justifications for actions tend to cluster in three general moral schemas based on: protecting personal interests maintaining (PI), upholding rules and norms (MN), and applying universal ethical principles (often referred to as “post-conventional thinking” and measured as N2 scores).

PIF와 도덕적 개발 이론적 틀 모두가 건설적인 발달 이론 (예 : Piaget, Kohlberg)에서 공유 된 기초를 가지고 있다고 가정 할 때, 우리는 그것들이 상호 연관 될 것으로 기대할 수 있다.

Given that both PIF and moral development theoretical frameworks have a shared basis in constructive developmental theories (e.g. Piaget, Kohlberg), we would expect them to be correlated.

Methods

교육과정 맥락

Curricular context

A decade ago, along with many medical schools, we implemented a case-based and student-led professionalism curriculum spanning our four-year curriculum (Horlick et al. 2009) and an online portfolio to promote learners’ professional development (Kalet et al. 2007).

In 2015, (class of 2019), we introduced PIF during orientation, using the framework of Cruess (Cruess et al. 2014) and Bebeau (Bebeau & Faber-Langendoen 2014).
To facilitate self-awareness students completed both the PIE and the DIT2. On average, students completed both instruments within an hour.
Three weeks later, students received a detailed, individualized, six-page narrative feedback report from an expert (VM) (See Supplementary Appendix).
During a large-group debriefing session, the concepts of PIF were reviewed and students wrote portfolio reflections to the following prompts:
“Now that you have received your feedback, write your first impressions of your PIE and DIT2 information – What surprised you? What “rings true”? What information is helpful to you?”

채점과 분석

Scoring and data analysis

전문직 정체성 에세이

Professional identity essay scoring

PIEs were scored by a lifespan, developmental educational psychologist (VM) with expertise in measurement of moral capacities in professional education (Lahey et al. 1988; Bebeau & Monson 2012). Each student was assigned a Kegan PIF stage score in an individualized report with narrative feedback to each student. Five months later, the primary rater (VM) re-rated and a second trained rater rated 12 randomly selected PIEs (10%) to establish reliability (inter-rater ICC 0.83, 95% CI [0.57–0.96], intra-rater ICC 0.85, 95% CI [0.50–0.93]).

DIT 점수

Defining issues test scoring

The Center for the Study of Ethical Development at the University of Alabama (Development) scored DIT2s using established algorithms and provided metrics of students’ preferred moral schema (personal interest, maintaining norms, post conventional (N2)). For simplicity in this paper we report only the N2 score, which reflects the proportion of time students applied a social contract orientation or universal principles approach to the cases.

양적 분석

Quantitative

질적 분석

Qualitative

A directed and summative content analysis of students’ reflections was conducted by two readers (SY, RC) (Hsieh & Shannon 2005).
The first reader (SY) defined a set of thematic categories and subcategories (Table 3) which were then grouped into three clusters:

긍정적 반응 positive responses (student reported feeling positive about the exercise, or feeling positive about the journey ahead of them in medical school),
중립적 반응 neutral responses (student discussed metrics, had an analytic approach to their data), and
부정적 반응 negative responses (students reported disappointment with their feedback, or reported feeling negative or confused about the exercise).

After a training set (30) during which two readers (SY, RC) discussed disagreements to they resolve discrepancies, each independently applied the code categories to each student’s reflections.
Table 3 shows the frequency for the 9 of 17 response categories that showed adequate inter-rater reliability (Cohen’s kappa >0.300) (Landis & Koch 1977). The remaining categories were useful for descriptive purposes and hypothesis generation.

결과

Results

The correlation between N2 score and Kegan PIF stage was q¼ 0.18 (p¼0.03). The mean DIT N2 differed by Kegan PIF stages (early, 52.0 (SD¼11.8) vs. late, 56.0 (SD¼11.1) (p¼0.046).

내용 분석과 DIT 점수

Content analysis of student reflective writing on PIE stage and DIT score report

Table 3 lists identified themes. Of the 130 students,

117 (90%) reported positive reactions to the PIF curriculum.
Mixed negative reactions (28/130, 21%, not mutually exclusive) included confusion, concern about future training, or dissatisfaction with the gap between their self-perception and the results.
Very few reported only negative reactions. Students who described an analytic approach to evaluating their feedback tended not to report negative reactions, even when they were surprised by the feedback.

고찰

Discussion

우리는 각 학생에게 PIF 단계를 제공하고, 선호하는 도덕적 추론 스키마 및 개별화 된 피드백을 제공하는 것이 타당하다는 것을 발견했습니다. 이 접근 방식은 학생들에게 받아 들여지고 흥미로우며 잠재적으로 역량 기반 전문성 커리큘럼에 대한 접근 방식으로 유용합니다.

We found that it was feasible to provide each student with a PIF stage, their preferred moral reasoning schema and individualized feedback. This approach is acceptable and intriguing to our students and potentially has utility as an approach to competency-based professionalism curricula.

우리 학생들의 Kegan PIF 단계 분포는 다른 비슷한 연령대의 전문직 학생과 유사합니다 (Bebeau & Monson 2012). other-defined 정체성에서 self-defined 정체성 (단계 3-4)으로 바뀌는 것은 완전히 발달 된 직업적 정체성의 신호이다(Bebeau 2008). 엄격하게 나이에 좌우되지는 않지만, 대부분의 북미 의사들은 레지던트 훈련 후인 30 대 초중반 사이에 이러한 shift가 가장 자주 발생합니다. 따라서 우리는 의사들에게 PIF에 대한 장기적인 관점을 가져야합니다. 일반 인구의 많은 성인들이 케건의 청소년기 (2 단계, 13 %) 또는 초기 성인기 (3 단계, 46 %)와 1 % 미만의 단계 (5 단계 Kegan & Lahey 2009)를 벗어나 발전하지 못합니다.

The distribution of the Kegan PIF stages among our students is similar to that of other age-comparable professional students (Bebeau & Monson 2012). Fully-developed professional identity is signaled by the shift from ther- to self-defined identity (stage 3–4) (Bebeau 2008). While not strictly age-dependent, this shift most often takes place at the age of early- to mid-30s – which is after residency training for most North American physicians. So we must take a long-term view of PIF in physicians. Many adults in the general population do not develop beyond the Kegan stages of adolescence (stage 2, 13%) or early adulthood (stage 3, 46%) and less than 1% achieve stage 5 (Kegan & Lahey 2009).

그러나 의사들이 우리의 사회적 계약을 존중하기 위해 평균 성인보다 더 높은 수준에 도달해야하느냐에 대해서는 논쟁의 여지가 있습니다. 도덕적 정체성에 대한 연구에서 PIF의 후기 단계에있는 사람들은

다른 사람들에게 봉사하는 데 집중할 가능성이 높고,
관심사가 이기심에 의해 동기 부여될 가능성이 낮으며,
동료들에 의해서 효과적이라고 인식될 가능성이 높고,
잠재 커리큘럼(알려진 것과 실제로 가르쳐지는 것) 사이의 단절에 덜 취약합니다(Kegan & Lahey 2016).

However, it is arguable that physicians must reach higher levels than the average adult to honor our social contract. In studies of moral identity, those at later-stages of PIF are

more likely to focus on service to others,
less likely to articulate concerns motivated by self-interest,
be perceived as more effective by peers (Kegan & Lahey 2016), and
less vulnerable to the disconnect between what is taught and what is actually practiced – known as the hidden curriculum (Kegan & Lahey 2016).

일반적으로 우리 학생들은 exercise에 의해서 활성화되었고, 그들의 baseline PIF에 대해 알게되었습니다. PIF 피드백에 대한 분석적 접근과 초보자로서의 자신에 대한 인식을 가진 사람들은 (숙달 획득에 대한 기대를 포함하여) 정서적으로 긍정적 인 반응을 나타내는 경향이있었습니다. 개인화된 PIF 단계 데이터는 '프로페셔널리즘의 결여'에 초점을 맞춘 대화를 '전문적 "지혜"' 개발에 대한 숙달 접근법에 대한 대화로 확대 시켰습니다(Rees, 2005; McGaghie 2015).

In general, our students were activated by the exercise and intrigued to learn about their baseline PIF. Those with an analytical approach to their PIF feedback and an awareness of themselves as novices tended to have emotionally positive responses, including anticipation of acquiring mastery. Personalized PIF stage data expanded the conversation beyond a focus on lapses in professionalism into a conversation about a mastery approach to the development of professional “wisdom” (Rees, 2005; McGaghie 2015).

생각 지도자는 성인 발달의 선형 단계 모델이 너무 단순하다고 지적하며 (Rees 2005), 우리는 여기에 동의합니다. 우리는 의대생의 PIF가 부드럽거나 예측가능하거나 선형적인 방식으로 진행될 것으로 예상하지 않으며, 경로는 개별화되어있고, 맥락에 민감할 것이라고 생각한다. 그러나 아직 알려지지 않았기 때문에 우리가 이 연구를 한 것이다.

Thought leaders argue that linear staged models of adult development are too simplistic (Rees 2005) and we agree. We do not anticipate that PIF in medical students proceeds in a smooth, predictable, linear manner and fully anticipate it will be shown to have individualized paths and be context sensitive. But, it is not yet known, and therefore why we are pursuing this work.

예상보다 낮은 PIF 무대 점수를 받은 소수의 학생들이 실망한 것은, 이것이 평생 성장 단계가 아니라 결함이라는 인식을 반영 할 수 있습니다. 이러한 입장은 학습을 방해 할 수 있습니다 (Blackwell 외. 2007). 의대생은 개인 성취도에 따라 선발되기 때문에, 개인 성취도에 중점을 둔 의대 진학이 적절합니다. 그러나 그들은 사회 계약에 의해서 정의 된 의료 전문직의 원칙과 가치에 헌신하는 방향으로 옮겨가야 한다. 이것은 실천 공동체의 구성원이 되는 복잡성을 address하겠다는 의지를 의미합니다 (Hafferty & Levinson 2008; Levinson 외 2014).

The disappointment of a small number of students receiving earlier than expected PIF stage scores may reflect their perception that this is a flaw rather than stage in life-long growth. This stance can interfere with learning (Blackwell et al. 2007). Since medical students are selected based on their individual accomplishments, it is appropriate for them to enter medical school focused on personal achievement. However, they must move on to commit to the principles and values of the medical profession as defined by our social contract. This means a commitment to addressing the complexities of being a member of the community of practice (Hafferty & Levinson 2008; Levinson et al. 2014).

학생들이 피드백을 찾고 자신의 전문성 개발에 관한 대화에 참여하는 학습 문화를 통해서 [자신의 정체성은 완벽하거나 거의 완벽한 성취에 의해서만 보여진다로 느끼는 학생들]이 사고 방식을 바꾸는 것을 가능하게합니다. 이러한 방식으로 자기를 돌아볼 수 있는 의사들은 의료의 문화를 경쟁적 문화를 협력적 문화로 변화시키기 위해서 필요하다 (Hafferty & Castellani 2010). 왜냐하면 이러한 문화는 환자의 건강은 물론, 점점 경쟁이 치열해지는 시장에서의 조직의 생존 능력과도 연관되어 있기 때문이다(Brennan & Monson 2014).

A learning culture in which students seek feedback and engage in dialog about their professional development enables the needed shift in mindset for students who feel their identity is only reflected in perfect or near perfect achievements. Physicians capable of such introspection are needed to lead change in the culture of medical practice from competitive to cooperative (Hafferty & Castellani 2010), because such a culture is associated with improved outcomes for both the health of patients and organizations’ ability to thrive in an increasingly competitive marketplace (Brennan & Monson 2014).

Conclusions

전통적으로 의학 전문 직업에 대한 가르침은 미덕, 성격 "특성"및 예상되는 행동에 초점을두고 있습니다. 수십 년 동안 우리는 전문성의 행동적 징후를 해체하고 측정 가능한 역량을 생성해냈다 (Irby & Hamstra 2016). 도덕적 추론과 전문적인 가치에 헌신하는 능력이 강할수록 medical trainee는 전문성의 결여를 초래할 수있는 상황 요인 (예 : 피로, 모호함, 정서적 스트레스)에 덜 susceptible해질 수 있다. 성격 및 행동 관점에, 심리적 발달적 구조를 추가함으로써, 우리는 직업적 정체성과 전문성을 이해할 수 있으며, 더 중요한 것은 학생이 어떻게 "의사처럼 생각하고 행동하고 느끼는"과정에 영향을 미칠 수 있는가를 학습 할 수 있습니다 (Cruess et al., 2014).

Traditionally, teaching about medical professionalism is focused on virtues, character “traits”, and expected behaviors. Over several decades, we have deconstructed the behavioral manifestations of professionalism and created measurable competencies (Irby & Hamstra 2016). A strong capacity for moral reasoning and commitment to professional values makes medical trainees less susceptible to situational factors (e.g. fatigue, ambiguity, emotional stress), which may cause lapses in professionalism. By adding a psychological development framework to character and behavior perspectives, we can better understand professional identity and professionalism and, more importantly, how the students themselves can influence the process of being able to “think, act, and feel like a physician” (Cruess et al. 2014).

Glossary

전문직 정체성 형성

Professional Identify Formation:

Medical professional identify formation (PIF) is both a process of personal development and a social construction and has long been claimed to be the fundamental goal of the learning process in medical education (Cooke et al. 2010).

In 1957, Merton stated that the task of medical education is to provide the medical trainee “with a professional identity so that he comes to think, act, and feel like a physician” (as quoted by Cruess et al. (2016), italics theirs).”
It has been further defined as an ongoing, self-reflective process aimed at developing habits of “thinking, feeling and acting” that allow learners to be compassionate and socially responsible physicians (Cooke 2010 quoting Ware and Castelini 2000).

A staged, developmental framework for PIF has been applied in health professions education (Bebeau & FaberLangendoen 2014). There is an enthusiastic dialog in the medical education literature about whether PIF can be measured. And it was recently proposed that we add PIF to the tip of Miller’s Pyramid for the assessment of clinical competence and performance (Cruess et al. 2016).

Bebeau MJ, Faber-Langendoen K. 2014. Remediating lapses in professionalism. In: Kalet A, Chou C, editors. Remediation in medical education. New York: Springer; p. 103–127. XXX

~~McGaghie WC. 2015. Mastery learning: it is time for medical education to join the 21st century. Acad Med. 90:1438–1441.~~

~~Goldie J. 2012. The formation of professional identity in medical students: considerations for educators. Med Teach. 34:e641–e648.~~

~~Wynia MK, Papadakis MA, Sullivan WM, Hafferty FW. 2014. More than a list of values and desired behaviors: a foundational understanding of medical professionalism. Acad Med. 89:712–714.~~

Med Teach. 2017 Mar;39(3):255-261. doi: 10.1080/0142159X.2017.1270437. Epub 2016 Dec 30.