새로운 방식의 의과대학 임상실습과정이 환자-의사 사이의 의사소통을 향상시킬 수 있을까?

새로운 방식의 의과대학 실습과정이 환자-의사 사이의 의사소통을 향상시킬 수 있을까?

Can a novel med school curriculum improve doctor-patient communication?

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Posted on February 12, 2013 by Stacy Lu

병원에서 일해본 경험, 혹은 환자로 입원해본 경험이 있는 사람이라면 대학병원에서 실습을 하는 3학년 학생의 모습을 떠올려볼 수 있을 것이다. 교수가 지나가고, 시끌벅적한 학생들이 따라간다. 교수는 환자에 대해 몇 마디를 던지고, 학생들은 고개를 끄덕이거나 노트를 적고, 교수는 나가고 수행단이 뒤따른다. 그리고 다음 과 실습이 시작되면, 그 환자는 영영 다시 보지 않는다.

Anyone who has worked – or been a patient — in a large teaching hospital knows what a traditional third-year medical student clerkship can look like: Specialist sweeps in, accompanied by a gaggle of students; specialist has a few words with the patient; students nod and occasionally take notes; specialist leaves, accompanied by retinue.  Students move on to next rotation and never see patient again.

비교적 새로운 모델인 Longitudinal Integrated Clerkship (종적통합임상실습, LIC)는 이것을 완전히 바꿔놓았다. 백년이나 된 기존의 낡은 '블록식' 모델을 개선해보자는 것에 대한 한 가지 대안이다.

A relatively new model, the longitudinal integrated clerkship (LIC), wants to change all that.  It answers decades of increasing calls from the medical education community to revise the prevailing century-old current “block” model of clinical learning, which can present fragmented views of disease and allow only snips of caregiving in the current outpatient care-based healthcare system.

LIC에서 학생은 핵심과의 멘토와 함께 임상실습을 하는 기간동안 한 케이스의 시작부터 끝까지를 함께한다. 프로그램 중심이라기보다는 환자 중심이다. 현재는 미국, 호주, 캐나다, 남아프리카의 15개 학교에서 주로 만들어 시행하고 있지만, 100개 이상의 학교가 국제컨소시움에 합류, 논의중에 있다.

Within an LIC, students work with mentors in core specialties on their principal clinical year and follow cases from beginning to end — be that an hour, a day or a year — in a process that is patient- rather than program-oriented. It is designed to give students a broader and more empathetic view of healing, and lasting lessons in doctor-patient relationships and communication. Some 15 schools in the U.S., Australia, Canada and South Africa have large and established programs, but more than a 100 schools have joined an international consortium to discuss and explore the option.

"학생은 팀의 구성원으로서 환자에 대해 많은 것을 배워간다. 질병의 진화과정을 보고, 환자를 따라다니며 회복은 하는지, 대단원의 마지막을 보고, 임상적 의사결정의 결과를 본다." David Hirsh.

“Students are there as things unfold for the patient. They are part of the team. They see the evolution of the disease. They follow patients long enough to see them recover, to see the denouement and the outcome of their decisions,” says David Hirsh, MD, director and co-founder of the Harvard Medical School-Cambridge Integrated Clerkship at Cambridge Health Alliance, assistant professor of Medicine at Harvard Medical School, and lead author of the most comprehensive study of program results to date.

지난 3월 Academic Medicine에 발표된 이 연구에서 LIC 학생들은 동료들과 비교할 때 지식 측면에서 동등하며, 환자중심적 진료에 더 잘 준비되었다고 느낀다는 것이 보고되었다. 

In that study, published last March in Academic Medicine, LIC students performed at least as well as their peers on measures of content knowledge, and reported feeling much more prepared in patient-centered aspects of care, including handling ethical dilemmas, involving patients in decision-making, and relating well to a diverse population.

Patient Care With Context

학생들의 만족감이 더 높았고, 당연히 환자들도 이러한 식의 구성을 더 선호했다.

Students also reported a higher level of satisfaction with their med school education. Not surprisingly, patients seem to like the arrangement, too.

"저를 담당하는 의대생이 있는 것이네요"  "학생은 어디갔어요? 그 학생이 있으면 회진돌 때 마음이 조금 더 편안해지거든요" 환자들은 이렇게 말한다.

“ ‘I have my own personal medical student,’ ” they’ll say. And to me, they’ll say, ‘Where’s your student today? Because you’re a much better doctor when your student is around.’ ” Hirsh says.

학생 역시 환자의 가치나 사회적 맥락을 더 잘 이해하고, 의사소통의 방해물이 되는 요소가 무엇인지 더 잘 짚어낸다.

Students in an LIC are also ideally better able to understand a patient’s values and social context and to spot communications roadblocks. As one student wrote in a reflective narrative on the LIC experience:

"제가 아니었으면 가족의 지원은 충분히 받지만 문맹에다가 영어도 잘 못하는 이 환자는 분명히 망가졌을거에요. 예정된 일정이나 의사소통, 의사소통의 양, 그리고 의사소통이 잘못 이루어지는 경우가 너무 흔해서 과정이 길어지고 환자를 잃게 되었을걸요"

“Without me I can confidently say this illiterate, non-English-speaking patient, even with his very supportive and involved family, would have fallen through the cracks. The number of appointments and communications and miscommunications would have been so numerous, and it would have taken so long, that he probably would have just stopped showing up.”

"학생은 단순히 과제를 하는 것도 아니고, 사례 학습 목적으로 환자를 보는 것도 아니에요. '6번 방의 간환자'가 아니라는 거죠. 환자는 몇 달 동안 내가 알아온, 그것도 매우 잘 아는 OOO씨인 것이죠"

“It’s not the student just accomplishing some task. Nor are they seeing the patient as  a case study. It’s not ‘the liver in room six’ – it’s ‘Mrs. So-and-So whom I have known many months, whom I know well,’ ” Hirsh says.

환자 결과가 어떤지는 연구된바가 없지만, LIC에서 분명히 더 나을 것이라 생각한다.

Though patient outcomes haven’t yet been studied, Hirsh believes an LIC, in which students navigate our complex healthcare system in tandem with their patients, can also give them a better vantage point from which to treat chronic disease.

“For example, say a diabetic patient has low blood sugar. You’re there for that, and you’re there for the treatment. Commitments are fostered. You might try harder to help with education and secondary prevention. There comes a stronger desire to learn, ‘Who is that person? Who is that patient?’ “ he says.  As another student wrote,

“Each time we see Ms. O, attempting to understand her evolving health adds another piece to our medical repertoire. Each time we grow to understand a bit more about the toll that hospitalizations and chronically deteriorating health can have on a patient and her family.”

A Lasting Humanism

무엇보다도, LIC를 하고 졸업한 학생은 의사가 되 이후에 휴머니즘을 더 갖추고 있을 것이다.

Perhaps most significantly, graduating from an LIC can give a future doctor a better grounding in the humanism necessary to her or his profession, Hirsh says.

연구에 따르면 의과대학 학년이 올라갈수록 의대생들은 더 시니컬해지고, 환자 중심적인 면모도 더 잃어간다.

Research suggests that as students progress through medical school, med students become more cynical, with a resulting decline in patient centeredness.

"도덕적 성장이 안 되는 것이죠. 공감능력이 점차 낮아져요. 의학이 추구하는 목표와는 정반대인 것이죠. 우리는 우리 학생들이 스스로 최고의 모습을 갖출 수 있도록 지속적으로 노력하고 가꾸어기를 바랍니다."

“Their moral development is shattered, their empathy is declining – how can that be? That’s the opposite of medicine’s goals. We want to sustain and nourish our students to be their best selves. Who they will be when they’re doing their life’s work?” Hirsh says.

반대로 Hirsh의 연구결과는 LIC를 하는 동안 환자중심적인 태도가 더 향상된다는 것을 보여준다.

In contrast, Hirsh’s research shows that students show an increase in patient-centeredness as they go through their training as compared to those doing a traditional clerkship.

From a student:

“I’ve heard traditional third- year students describe their horror at the sight and smell of the necrotic feet seen in vascular clinic. It had never occurred to me to be disgusted by F. When we noticed the first signs of an ulcer on her toe and when erythema gave way to necrosis, then osteomyelitis, I remember feeling concern, but not disgust. And when we finally had to serially amputate her forefoot, I remember thinking only that I wanted to do right by her—to find vital tissue. “

"윤리는 학생이 얼마나 의미있는 역할을 하고 있느냐와 관련이 있습니다. 학생은 환자를 더 중요하게 생각할 필요가 있고, 환자 역시 학생을 더 중요하게 생각할 필요가 있습니다."

Hirsh says, “Ethics has to do with the students having meaningful roles. The student needs to matter to the patient, and the patient needs to matter to the student.

"우리 학생들이 과학을 더 공부하고 싶어하는 이유는 바로 환자를 돕고싶고 싶은 마음 때문입니다"

“Our students want to know the science because they want to help their patient.”

(출처 : http://blog.tedmed.com/?p=2736)