혼돈의 한 가운데서 레지던트에게 '돌봄(caring)'을 가르치기

실패를 두려워하면 시스템을 변화시키지 못한다.

(출처 : http://medicinex.stanford.edu/2011/12/01/a-patient-patient-sarah-kucharski-writes-about-life-with-fibromuscular-dysplasia/)

절대로 그 옛날 시절에 수련을 받던 레지던트보다 

지금의 레지던트가 의사라는 직업의 임무에 덜 충실하다고는 생각하지 않는다. 

하지만 '책임'이라는 것이 마치 빠른 속도로 회전하는 회전문과 같을 때, 

돌봄(caring)의 정의는 바람직하지 않은, 그리고 우리가 의도하지도 않은 방향으로 변질될 수 있다. 

만약 그러한 위험이 존재한다면, 우리는 이것에 대해 이야기 해볼 필요가 있다.

We are certain that today’s trainees are not a whit less dedicated to their professional mission than those of an earlier era were at their best,8 but we cannot help wonder whether the very definition of caring changes in undesirable and unintended ways when responsibility becomes a rapidly revolving door. If that risk exists, it warrants conversation.

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1970년대에 레지던트를 하는 것은 비교적 간단한 일이었다. 치료의 방법이 단순했고, 정보는 면대면 대화나 전화를 통해서, 노트나 편지를 통해서 전달되었다. 의사는 팀으로 일했고 모든 팀원은 한 병동에 대해 공동의 책임을 졌다.

FOR PHYSICIANS WHO WERE RESIDENTS IN THE 1970S (like we were), it was a simpler era for care. 

- A relatively small number of medications were available for treatment and prevention of illness

- Information was exchanged by synchronous face-to-face and telephone communication or by written notes and letters.

- Physicians and surgeons worked in teams, whose members shared responsibility for the territory of specific patient wards

무엇보다 레지던트들은 한 환자가 입원을 하는 순간부터 퇴원을 할때까지 전 과정에 대한 책임이 있었다.

Residents showed their investment in the well-being of patients by taking responsibility for them during the full length of time those patients were hospitalized, starting with their admission.

그러나 2013년, 대학병원 입원환자에 대한 의료는 변화되었다. 여러가지가 있지만, 주치의가 빠르게 순환해서 종종 1주나 2주면 바뀌게 된다.

In 2013, inpatient medical care in teaching hospitals is different: far more complex, more intense, and, simply put, faster. The arsenal of diagnostic tests, medical therapies, interventional technologies, and health care professionals is much larger. Attending staff have shorter rotations, often 1 or 2 weeks.

For good reasons, resident work schedules have fewer total and consecutive hours.

Team schedules seem less synchronized, and turnover of members seems more frequent

처음에 입원을 담당한 의사가 그 환자의 최종 결과까지 책임지지는 않는다.

The length of time a single physician bears responsibility for a patient may be as short as a few hours. The inevitable result is an increase in the proportion of time a hospitalized patient is cared for by physicians who neither initiated a care plan nor will be responsible for (or perhaps even aware of ) the final outcome.

Communication patterns are now fundamentally different from those of the earlier era, due to technological progress in electronic and mobile communication

The electronic health record (EHR) has pulled both the resident and attending physicians’ focus toward the computer instead of the patient,2 and the contemporary EHR has become a series of often unrelated notes.3

속도의 변화, 복잡성의 변화, 반복되는 업무교대가 미치는 영향에 대해서 따져볼 필요가 있다.

It is worth asking what the effects of such speed, complexity, and continual handoffs may be on the perspectives of the physicians involved—both for trainees and attending physicians

이러한 해결책으로 팀을 구성하는 것도 한 가지 방법이나, 레지던트의 반복적인 교대가 개인에게 미치는 영향은 팀에게도 동등하게 적용될 수 있다.

One remedy is an effective clinical team, which can and does help mitigate the risks of rapid turnover and diffused responsibility. However, the same dynamics that can erode an individual’s mastery of patient histories can also impair teamwork. Changing team members every 2 weeks, or even more often, can confound the best intentions of the workforce.

지난 날을 미화시키려고 하는 것은 아니다.하지만 '책임' 과 '돌봄'의 의미가 무엇인지 고민해볼 필요는 있을 것이다.

These observations should not be interpreted as advocating a return to the imaginary “good old days” of everyother- night on call and brutally long working shifts; these conditions bred hazards and wrong lessons of their own. Nor should anyone ignore the importance of improving handoffs in patient care, which have now become crucial to excellence. 1 But perhaps, in this relay-race era of rapid turnover, it would be worthwhile for teachers and trainees together to examine explicitly what the profession means by the notions of “responsibility” and “caring”when a trainee’s touch time with a single patient may be bounded in minutes or hours (not weeks or months), and when an attending physician may come and go from the hospital ward faster than the patient.

만약 시니어, 주니어, 레지던트가 최선의 노력을 다하고 있음에도 제대로 된 caring이 이뤄지고 않다고 느낀다면, 시험적으로 몇몇 변화를 시도해 볼 수 있다.

If senior physicians, younger attendings, and current residents are concerned about coming up short on caring despite their best efforts, some changes may be worth testing systematically.4

more studies could be undertaken to determine whether rotations for residents and attending physicians should be lengthened or better synchronized.5 Methods of reducing stress that leads to burnout could be developed that might enable rotations to be lengthened, including reducing the need for onerous, duplicative, and usually useless  documentation by both attendings and residents.6

other solutions will be needed to increase the sense of longer-range responsibility. For example, both attendings and trainees could systematically receive follow-up on patients about whom they had made decisions.

We are certain that today’s trainees are not a whit less dedicated to their professional mission than those of an earlier era were at their best,8 but we cannot help wonder whether the very definition of caring changes in undesirable and  unintended ways when responsibility becomes a rapidly revolving door. If that risk exists, it warrants conversation.

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JAMA. 2013 Mar 13;309(10):987-8. doi: 10.1001/jama.2013.620.

Teaching physicians to care amid chaos.

Detsky AS, Berwick DM.

Source

Institute for Health Policy, Management and Evaluation and Department of Medicine, University of Toronto, Toronto, Ontario, Canada. adetsky@mtsinai.on.ca

PMID:

 

23483169

 

[PubMed - indexed for MEDLINE]