의학교육에서 의료인문학(Med Teach, 2018)

의학교육에서 의료인문학(Med Teach, 2018)

Medical humanities in medical education and practice

Hedy S. Walda,b, Jonathan McFarlandc and Irina Markovinac

도입

Introduction

의료인문학은 무엇이며 오늘날 의학 교육에 왜 중요한가?

What is Medical Humanities (MH) and why is it important for medical education today?

의료인문학은 새로운 것이 아니다. 1920년대까지 거슬러 올라가면, Peabody(1927년)는 "환자 돌봄의 비결은 환자를 돌보는 것이다"라고 주장했고, 50년 후 Pellegrino(1984)는 다음과 같이 믿었다. "의학은 기술적, 도덕적 질문을 임상적 의사결정에 연결시킨다. 의학은 객관적이면서 동시에 연민이 있어야 한다. 의학은 과학과 인문학 사이에 자리 잡고 있으며, 온전히 둘 중 하나에 해당하지 않으며, 두 가지의 특성을 모두 지니고 있기 때문이다."

Medical Humanities is not new. As far back as the 1920s, Peabody (1927) famously claimed that “the secret of the care of the patient is in caring for the patient,” and fifty years later, Pellegrino (1984) believed that “medicine connects technical and moral questions in its clinical decisions: it is required to be both objective and compassionate. It sits between the sciences and the humanities being exclusively neither one nor the other but having some of the qualities of both.”

MH의 정의는 매우 다양하며, Ahlzen(2007)이 언급했듯이, 이처럼 정의가 다양한 것은 (약 30년 전에 의학 윤리학이 그러했듯) 학문의 번영과 성숙의 신호이다.

Definitions of MH abound, and this, as Ahlzen (2007) mentions, is a sign of a thriving and mature discipline, similar to what occurred with medical ethics approximately thirty years ago. 

그러나 다음의 정의는 특히 적절해 보인다. "질병, 장애, 의료 개입에 대한 인간의 경험을 기록하고 해석하기 위한 통합적이고 간-학제적이고 철학적인 접근..."

The following definitions, however, seem particularly pertinent: “an integrated, interdisciplinary, philosophical approach to recording and interpreting human experiences of illness, disability, and medical intervention…” (Evans 2002) 

"의료에 대한 지식이 있고 민감한 제공자, 환자 및 가족 간병인을 양성하기 위해, 건강과 질병의 인간적 조건을 이해하는 것을 다루는 학제간 분야" (Klugman 2017). 

and “an interdisciplinary field concerned with understanding the human condition of health and illness in order to create health care knowledgeable and sensitive providers, patients, and family caregivers” (Klugman 2017). 

MH 의학 교육의 목적을 추구하기 위하여 "문학, 예술, 창조적 글쓰기, 드라마, 영화, 음악, 철학, 윤리적 의사 결정, 인류학, 역사 등 다양한 분야의 창조적이고 지적인 강점"에서 도출된다

MH draws on the “creative and intellectual strengths of diverse disciplines including literature, art, creative writing, drama, film, music, philosophy, ethical decision making, anthropology, and history" in pursuit of medical educational goals (Kirklin 2003).

히스(2016년)에 따르면, "증거 기반 의학은 우리를 생물 의학의 자료로 사람들을 묘사하도록 유혹합니다: 이것들은 충분하지 않고 앞으로도 충분하지 않을 것입니다. 그러한 증거는 필수적인 것이지만 항상 환자 치료에 불충분하다. 그것은 우리에게 알파벳을 제공하지만 임상의사로서 우리는 여전히 언어에 대한 확신이 없다."

According to Heath (2016), “evidence-based medicine tempts us to try to describe people in terms of data from biomedical science: these are not and will never be, enough. Such evidence is essential but always insufficient for the care of patients. It gives us an alphabet but as clinicians, we remain unsure of the language.”

인문/예술이 의학 교육에 통합되면 학습자가 전문직업성, 자기 인식, 커뮤니케이션 기술, 성찰연습과 같은 필수적 자질을 개발하는 것을 지원할 수 있을 것이라고 제안된다(Mann 2017; Wald et al. 2015). 고든(2005년)에 따르면 의료인문학은 의료와 인간의 단절을 극복할 수 있을 것이다.

Integration of humanities/arts into medical education, it is suggested, can support learners developing essential qualities such as professionalism, self-awareness, communication skills, and reflective practice (Mann 2017; Wald et al. 2015). According to Gordon (2005), the medical humanities can overcome the separation of clinical care from the human.

• 콜빈 외 연구진(2017)은 최근 MH가 대학원 의학 교육에서 어떻게 전문직업성, 사회적, 의사소통 "역량"을 촉진할 수 있는지를 강조한 반면, 

• 바티스타투 외 연구진(2010)은 MH를 개인적 및 전문직업적 가치의 구성construction을 보조하는 것으로 제안했다. 

• 치아바롤리(2017년)는 MH가 의사처럼 생각하는 것을 constitute한다고 믿는다. 

• MH는 의사 및 연수생들이 스트레스를 해소하고, 탈진 상태를 완화하며, 복원력을 강화하고, 웰빙을 촉진합니다(Gordon 2005; Wald et al. 2016. Wald). 

• 망고니온 외 연구진(2018)의 다기관 연구는 의대 학생들의 humanities에 대한 노출이 긍정적인 개인적 자질과 연관돼 있고 번아웃을 줄임을 보여주었다.

Colvin et al. (2017) recently highlighted how MH can promote professionalism, social, and communication “competencies” in graduate medical education whilst Batistatou et al. (2010) propose MH as aiding construction of personal and professional values. Chiavaroli (2017) believes MH help constitute what it means to think like a doctor. Data are emerging on MH helping physicians and trainees cope with and reduce stress, mitigate burnout, foster resilience, and promote wellbeing (Gordon 2005; Wald et al. 2016, Wald et al. 2018). Mangione et al.’s(2018) multi-institutional US survey recently revealed medical students’ exposure to the humanities correlating with positive personal qualities and reduced burnout.

어떻게

How

의사는 과학과 일반 문화 사이의 접점에 놓여 있다(Kleinman 1988).

Physicians are poised at the interface between the scientific and lay cultures (Kleinman 1988)

MH를 의학 커리큘럼에 어떻게 도입할 수 있는가?

How can the MH be introduced into medical curricula?

MH를 의학교육에 도입해야 한다는 의견의 일치가 존재하지만, 문제는 어떻게 해야 하는지이다. 예를 들면 통합적으로 해야 하는가 선택과목으로 해야하는가?

Even though a degree of consensus exists that the MH need to be (re)introduced into medical education, the question still arises as to how; whether, and for example, they should be integrated or perhaps, optional.

[어떻게 MH를 의과대학 커리큘럼에 배치할 것인가]와 [커리큘럼이 이미 과부하되어있다]라는 주장 사이에 긴장이 있다. 게다가, 이 논쟁에서 "소프트 스킬"과 "하드 스킬"이라는 잘못된 개념이 나타난다.

Tension regarding how to place MH within medical curricula exists, and the argument that medical curriculum is already over-burdened is a strong one. Moreover, within this argument, false concepts of “soft skills” and “hard skills” appear.

전 세계의 의학 교육 내에서 MH 커리큘럼 이니셔티브가 크게 증가하고 있다.

There is a great upsurge in MH curricula initiatives within medical education around the world.

세계적으로, 최근의 리뷰들은 인문학과 의학 윤리를 중국, 아일랜드, 이스라엘, 인도 등에서 의대의 기본적인 커리큘럼 구성요소라고 설명한다.

Globally, recent reviews describe humanities and medical ethics as fundamental curricula components of medical schools in China (Kosik et al. 2014), Ireland (Patterson et al. 2016; Walsh and Murphy 2017), and Israel (Reis et al. 2016) and emerging initiatives in India (Singh et al. 2017), for example.

커리큘럼에서 MH를 어떻게 평가할 수 있는가?

How can MH in curricula be assessed?

핀 외(2013년), "우리는 인문학이 제공하는 것을 적절히 포착하고 학제간 협력을 장려하는 평가 도구를 채택해야 합니다." 그러나 Pfeiffer 등(2016)은 (샤피로 외 연구진(2009)의 주장을 인용하여) 이 주제를 다룰 때 주의할 것을 권고했다. 그들은 [MH는] "테크니컬한 역량 평가를 위해 설정된 기준을 가지고는 효과적으로 판단할 수 없다."고 지적했다. 이와 마찬가지로, 벨링(2010)은 Ousager와 Johannessen의 (2010) MH 문헌 리뷰에서 "245개 연구 중 9개만이 실제 환자들에 대한 미래의 의사들의 태도와 행동에 장기적인 영향을 주었음"을 언급하며, "결과 측정의 무딘 도구에 대하여 효과적이고 설득력 있는 대안"을 확립할 것을 요구하고 있다. 

Fins et al. (2013), “we must adopt assessment tools that adequately capture what the humanities have to offer and encourage interdisciplinary collaboration that is sophisticated and rigorous.” Pfeiffer et al. (2016), however, encourage caution when tackling this topic, citing Shapiro et al.’s(2009) assertion that these [MH] “cannot be judged effectively by standards set for evaluating technical competency.” Along these lines, Belling (2010) in response to Ousager and Johannessen’s (2010) MH literature review outcome of “only 9 out of 245 studies provided evidence of long-term impact on future doctors’ attitudes and behavior with actual patients,” calls for the establishment of “effective and persuasive alternatives to the blunt tools of outcomes measurement.”

Kuper(2006)와 Lake 등(2015년)은 MH 평가를 위한 정성적 방법의 잠재적 가치를 강조한다.

Kuper (2006) and Lake et al. (2015) emphasize the potential value of qualitative methods for MH assessment

예술 기반 개입 학습 과정을 평가하기 위한 피드백과 성찰 포트폴리오를 활용한 면밀한 관찰이 제안되었다(Osman et al. 2018).

Close observation with feedback and reflective portfolios to assess the process of learning in arts-based interventions has been suggested (Osman et al. 2018).

의과대학 교과과정에 인문학을 포함시킬 필요성을 인정하면서도 한국 학생들은 이 주제에 대해 시험을 치르지 않는 것을 선호했다.

While acknowledging the necessity of including humanities in medical school curriculum, Korean students preferred not being tested on this topic (Hwang 2014).

Graham et al. (2016)과 Shapiro et al. (2004)은 어떻게 MH를 과목에 도입하는 것이 미국 의대생들의 공감을 증가시켰는지 보여주었다.

Both Graham et al. (2016) and Shapiro et al. (2004) have shown how introducing MH into coursework has increased empathy score outcomes in U.S. medical students,

정성적 분석에 따르면 홍콩 의대생들은 의사 역할뿐만 아니라 자기, 환자, 고통, 고통과 관련된 이해의 증가에 art-making의 이점을 관련시켰다(Potash et al. 2014).

qualitative analyses revealed that University of Hong Kong medical students related the benefits of art-making to an increase in understanding in relation to self, patients, pain and suffering as well as the role of the doctor (Potash et al. 2014).

대인 커뮤니케이션 기술(ICS), 유머 및 theater의 선택MH과목의 혼합 방법 평가는 인식, 태도, 자기 효율성 및 행동 측면에서 ICS와 유머 모두에 긍정적이고 중요한 영향을 미친다는 것을 보여주었습니다.

Mixed methods assessment of an elective MH course on interpersonal communication skills (ICS), humor, and theater revealed positive, significant effect on both ICS and humor in terms of perceptions, attitudes, self-efficacy, and behavior (Karnieli-Miller et al. 2017).

공식적인 미술 관찰 훈련이 어떻게 의대 학생들의 시각 진단 능력을 향상시키는지 주목하는 것은 흥미롭다.

it is interesting to note how formal art observation training has been shown to improve medical students’ visual diagnostic skills (Naghshineh et al. 2008; Gurwin et al. 2018).

Pattison(2003년)은 "인문학의 본질의 일부는 [즐거움, 예상치 못한 통찰, 그리고 심지어 지혜의 등장을 가능하게 하는] 내재적 가치와 측정 불가능한 가치"라고 논평했다.

Pattison (2003) comments, “Part of the essence of humanities is the sense of intrinsic value and non-measurable worth that may allow the emergence of pleasure, unexpected insight, and even wisdom” (p. 34).

떠오르는 MH 토픽들

Emerging topics in MH

1. 국제보건

1. Intersections between global health and MH

In the 21st century, medical education is concerned with the global outlook and thus global health initiatives and leadership are becoming increasingly important. In line with this, Adhikari (2007) highlights how MH can contribute to the development of a “global physician” as “incorporating language, art, music and history into the understanding of a culture allows one to design effective global health support for a community” (https://globalhealth.duke.edu/media/ news/mellon-grant-supports-exploration-global-healthhumanities, quoting D. Clements).

2. MH의 범위 넓히기

2. Broadening the MH span 

Also of consequence is an increased integration of MH into various healthcare professions educational curricula, including pharmacy (Ishikawa 2017), nursing (Freeman and Bays 2007; McKie et al. 2008), dentistry (Zahra and Dunton 2017), and physical therapy doctoral education (Manago and Gisbert 2017). 

In the workplace, MH has a role for “interdisciplinary understanding and cooperation” (Pattison 2003) as well as for “colleagues to interact outside typical disciplinary and hierarchical divides (e.g. promoting teamwork between physicians and nurses, surgery and anesthesia, patients and clinicians)” (Katz 2014, p. 612).

3. 테크놀로지 활용

3. Use of Technology 

Technology-enhanced learning has also come to the fore recently in helping to integrate MH into curricula and some examples are the digitization of a MH session for undergraduate medical education (D’Alessandro and Frager 2017), a blended learning curriculum approach (Sechenov University 2018), as well as an arts-based mobile app (BEAM, i.e. Bedside Education in the Art of Medicine) aimed at promoting reflection on a patient’s human experience of illness (Chisolm 2017). Effective use of combined humanities modalities such as photography and narrative (Wald and Weiner 2009) and abstract art and narrative (Karkabi et al. 2014) are topics for future inquiry.

4. 보건-전 교육에서 MH

4. MH in Pre-health Education

The expansion of MH or “health humanities” (Crawford et al. 2015) in pre-health education is gaining traction, with the Journal of Medical Humanities, for example, recently devoting a special themed issue to this topic (Berry et al. 2017). 

바론(2017, 페이지 482)은 pre-health 학생들에게 의학 교육 사다리의 초기 단계에서 MH를 사용하는 것은 "커리어로서뿐만 아니라 소명으로서도 의학에 대한 이해를 변화시킬 수 있다"고 강조한다.

Barron (2017, p. 482) emphasizes that using MH at such an early stage in the medical educational ladder with pre-health professions students can “shape their understanding of medicine not just as a career but also as a vocational calling.”

5. 일생에 걸친 의료인문학

5. MH throughout the professional life trajectory 

Just as it is of interest to introduce MH at an early stage in the health professional’s education, the same is true of continuing with this implementation throughout their lifelong career trajectory. A faculty development program used guided narrative writing to promote reflection and empathy among practicing physicians (Misra-Hebert et al. 2012) for example and increased empathy scores post-interprofessional narrative medicine program in Taiwan were sustained over 1.5years (Chen et al. 2017).

6. 회복탄력성과 웰빙

6. MH and Resilience/Wellbeing 

The role of MH in clinician (and trainee) resilience and compassionate practice is gaining appreciation within current concerns about health care professions student and practitioner wellbeing (Wald et al. 2016). In this context, reflective writing can be a “resiliency workout” within professional identity formation (Wald et al. 2015) and mandala art-making with reflective writing has been suggested as a “reflective activity to provide insight into evolving professional identity and the psychological state of students,” potentially helping educators nurture students’ wellbeing (Potash et al. 2016). Cultivating self-awareness and reflection on one’s own experience as well as patients’ experiences for meaning-making through narrative medicine can promote health professional wellbeing (Sands et al. 2008). Moreover, benefits extend beyond healthcare professionals as positive effects of art, art therapy, and literature/reflective writing for patient wellness are well documented (Safar 2014; Barnes 2015; Pennebaker and Smyth 2016) including art for cancer care (Kirshbaum et al. 2017). Benefits of MH can even extend to family caregivers (DiGangi 2015; Wald 2016).

결론

Conclusions

과학과 인문학을 '비판적 리얼리즘'에 통합하는 것은, 겉으로 보기에 연결될 수 없을 것 같은 두 개의 세계(존재의 물리적 토대와 삶의 경험) 사이에 중심기둥을 제공하는 것일 수 있다.

Integrating science and the humanities for ‘critical realism’ may be a new version of reality providing a central pillar between two seemingly unbridgeable worlds: the physical basis of our existence and the experience of living (Appleby et al. 2017)

의료 분야에서는 여전히 dualism이 존재한다. 이것은 히스(2016)가 "two sides of the consultation"이라고 부른 것으로, 질병 대 병고, 객관성 대 주관성, 기술적인 것 대 실존적인 것, 과학 대 시 등과 같은 것이다. 우리는 두 측면이 모두 중요하다는 것과 두 가지가 모두 정당한 가치가 있다는 것을 인정한다. 이 안에서, 의대생들이 훈련의 초기 단계와 그들의 직업에서 다음의 것을 배우는 것이 필수적이라고 믿는다: 의료행위란 절대 흑백의 이분법적인 것일 수 없다. 또한 "전문직 실천의 지저분함"과 인간의 복잡성에는 언제나 그러한 회색지대와, 불확실성, 의심과의 씨름이 존재할 것이다. 우리는 MH를 포함시키는 것이 이것에 대응하고 능력 있고 인정 많은 의사들을 양성하는 틀을 만드는데 필요한 것을 제공하는 데 도움이 될 수 있기를 바란다.

Dualism still exists in medicine; “the two sides of the consultation” as Heath (2016) notes, disease versus illness, objectivity versus subjectivity, technical versus existential, science versus poetry, and so on. We acknowledge the importance of both sides of the coin and that both are given their due value. Within this, we believe it is essential that medical students are taught, from early stages of their training and throughout their careers, that practicing medicine can never be black and white, and that grappling with the gray, uncertainty and doubt will always be present within the “messiness of professional practice” (Schon 1983) and human complexity. We hope that inclusion of the MH can support the imperative of medical education to respond to this and help to provide the necessary for framework cultivating competent and compassionate physicians.

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Med Teach. 2018 Aug 23:1-5. doi: 10.1080/0142159X.2018.1497151. [Epub ahead of print]

Medical humanities in medical education and practice.

Wald HS1,2, McFarland J3, Markovina I3.

Author information

1

a Warren Alpert Medical School of Brown University , Providence , RI , USA.

2

b Boston Children's Hospital-Harvard Medical School , Boston , MA , USA.

3

c Sechenov First Moscow State Medical University (Sechenov University) , Moscow , Russia.

PMID:

 

30134753

 

DOI:

 

10.1080/0142159X.2018.1497151