임상학습환경(Med Teach, 2019)

임상학습환경(Med Teach, 2019)

The clinical learning environment

Jonas Nordquista,b, Jena Hallc, Kelly Caverzagied, Linda Snelle,f, Ming-Ka Chang, Brent Thomah , Saleem Razacke , and Ingrid Philiberti

재정적 제약과 임상 생산성에 대한 기대는 교육 활동의 가용 시간에 부정적인 영향을 미쳤다(Norman and Dogra 2014; Kilty et al. 2017; Weiss et al. 2018) 연습생과 교사의 스트레스, 번아웃, 비인간화, 의료에서 정서적 고갈에 대해 악영향을 주었다 (Gruppen et al. 201).8; 메이시 재단 2018).

Financial constraints and clinical productivity expectations have negatively affected available time for educational pursuits (Norman and Dogra 2014; Kilty et al. 2017; Weiss et al. 2018) and have contributed to higher levels of stress, burnout, depersonalization, and medical emotional exhaustion in trainees and in their teachers (Gruppen et al. 2018; Macy Foundation 2018).

임상적 맥락에서 배우는 것은 건강 전문가 훈련의 토대이다. 여기에는 대안이 없다. 또한 많은 의료 시스템은 학습자가 환자에게 제공하는 서비스에 의존하며, 이를 교육 기관에서 제거하는 것은 환자 치료에 부정적인 영향을 미칠 수 있다.

Learning in a clinical context is foundational in the training of health professionals; there is simply no alternative. In addition, many healthcare systems rely on the service that learners provide to patients, and to remove them from teaching institutions may have a negative impact on patient care.

북미 지역의 연구들은 훈련의 맥락이 된 학습 환경의 질이 졸업 후 수년간 졸업생들이 제공하는 치료의 질을 예측하는 변수였다는 것을 보여주었다(Tamblyn et al. 2005; Asch et al. 2009). 또한 이는 해당 의사의 처방 패턴이나(Cadieux et al. 2007) , 환자 관리, 보건의료 자원의 활용에도 영향을 주었다 (Chen et al. 2014; Sirovich et al. 2014; Dine et al. 2015). 마찬가지로, 일반 외과의사의 합병증 비율은 그들이 훈련했던 레지던트 프로그램의 순위와 관련이 있었다. 더 높은 순위의 레지던트 프로그램은 낮은 합병증 비율과 관련이 있다(Bansal et al. 2016).

Studies from North America have shown that the quality of the learning environment that provided the context for training was a predictor of the quality of care provided by graduates for years after graduation (Tamblyn et al. 2005; Asch et al. 2009) and influenced prescribing patterns (Cadieux et al. 2007) and patient management and use of health care resources (Chen et al. 2014; Sirovich et al. 2014; Dine et al. 2015). Similarly, complication rates for practicing general surgeons were associated with the ranking of the residency program in which they had trained—with higher ranked residency programs correlated with lower complication rates (Bansal et al. 2016). 

따라서, CLE를 개선하기 위한 노력은 연습생이 환자 치료에 배우고 참여하는 환경에서 긍정적인 영향을 미칠 뿐만 아니라, 잠재적으로 향후 수십 년 동안 미래의 졸업생들의 의료행위에도 영향을 미친다. 이는 훈련 의사가 현재 의료 제공의 최전선과 의료 관행의 미래를 대표하기 때문에 미국의 임상 학습 환경 검토(CLER) 프로그램에 대한 근거를 제공한다(Weiss et al. 2013, 2018).

Therefore, efforts to improve the CLE not only have a positive impact in the settings where trainees learn and participate in patient care but also affect the practice of future graduates, potentially for decades to come. This provides the rationale for Clinical Learning Environment Review (CLER) program in the United States, as physicians in training represent both frontline of health care delivery today and the future of the practice of medicine (Weiss et al. 2013, 2018).

임상학습환경 - 개념의 모호성

The clinical learning environment–An elusive concept

임상 학습 환경은 임상/학습/환경의 세 가지 핵심 요소를 포함한다. 임상학습환경에 대한 초기 정의는 의료 교육 환경의 기후와 전반적인 분위기에 초점을 맞추었으며(Genn and Harden 1986) 학습이 발생하는 기후climate의 중요성을 강조했다(Roff and McAleer 2001). 메이시 재단(2018년)은 학습 환경을 다음과 같이 정의했다.

Clinical learning environments involve three key elements: clinical work; learning; and environment. Early definition focused on the climate and overall ambiance of the medical education environment (Genn and Harden 1986) and highlighted the importance of the climate in which learning occurs (Roff and McAleer 2001). The Macy Foundation (2018) defined the learning environment as: 

사회적 상호 작용, 조직 문화와 구조, 그리고 참가자의 경험, 인식, 학습을 둘러싸서 형성하는 물리적이고 가상적인 공간." 이러한 다양한 기존 정의들이 CLE 개념의 복잡성을 보여준다.

“…social interactions, organizational cultures and stru-tures, and physical and virtual spaces that surround and shape participants’ experiences, perceptions, and learning.”These differences in existing definitions highlight the complexity of the CLE concept

여기서 우리는 CLE를 그림에서 표시한 "작업 환경"(trainee가 환자 진료를 배우고 참여하는 임상적 상황)과 "교육적 맥락"(기대 학습 성과 및 평가 방식을 정의하는 실라버스, 교육과정, 목표) 사이의 중복된 공간으로 정의한다.1번.

In this thematic examination, we the define the CLE as overlapping space between the “work environment” (the clinical context in which trainees learn and participate in patient care), and the “educational context” (the syllabi, curricula, and goals that define methods for learning, expected learning outcomes, and assessment practices), shown in Figure 1.

학습환경 평가의 역사적 맥락

A historical perspective on assessment of the learning environment

커트 르윈의 1930년대와 1940년대 사회심리학 연구(Lewin 1947)는 교육적 기후를 측정하는 기구 개발의 토대를 마련하였다(Genn and Harden 1986, Palmgren 2016). 초기 연구들은 학습자들의 환경에 대한 인식이 "학생들의 인격적 욕구personality needs와 본질적으로 무관하거나 독립적"이라는 것을 보여주었다(Genn and Harden 1986).

Kurt Lewin’s research in social psychology in the 1930s and 1940s (Lewin 1947) laid the foundation for the development of instruments to measure educational climates (Genn and Harden 1986 and Palmgren 2016). Early studies showed that learners’ perceptions of their environment “were essentially unrelated to, or were independent of the students’ personality needs” (Genn and Harden 1986).

the Dundee Ready Educational Environment Measure or DREEM (Roff et al.1997)—

영국의 일반의학위원회가 발간한 첫 번째 TD 보고서는 의대생들이 이상적이지 못한 조건에서 train된다는 사실에 대한 결정적 담론을 열었다(GMC 1993). 이 보고서는 집단 괴롭힘, 성차별, 괴롭힘, 감독 품질 및 임상 교수진들 간의 부정적 롤모델과 같은 문제를 강조하여 임상 학습 환경의 기업이 교육자와 규제자의 주의를 끌게 했다(Roff et al. 2005 및 Palmgren 2016) 궁극적으로 이것은 환자 안전 문제였으며, 이는 의사라는 전문직에 대한 대중의 신뢰에 잠재적으로 파괴적인 영향을 미치는 것이었다.

The first Tomorrow’s Doctor report published by the General Medical Council in the UK opened a critical dialog on the suboptimal conditions under which medical students were trained (GMC 1993). The report highlighted problems such as bullying, gender discrimination, harassment, quality of supervision and the presence of poor role models among clinical teaching faculty, bringing the enterprise of clinical learning environments to the attention of educators and regulators (Roff et al. 2005 and Palmgren 2016) Ultimately, this was a patient safety issue with a potentially devastating impact on the public’s trust in the profession.

• the Postgraduate Hospital Educational Environment Measure (PHEEM)

• a result of the 1984 death of Libby Zion in a New York teaching hospital,

• The ground-breaking report To Err is Human by the Institute of Medicine

• the ACGME instituted a national limit on work hours for physicians in training (Philibert et al. 2002).

유럽에서는 1998년 유럽 근로시간지침을 이행함으로써 훈련의 내과의사의 근무시간이 크게 단축되었다(다타와 데이비스 2014). 여기에 대해서 의료계는 엇갈린 반응을 보였다(Maisonneuve et al. 2014). 특히 외과 전문의의 훈련에 부정적인 영향을 미칠 것이라고 보았으며 (Hopmans et al. 2015), 연습생 근무 조건 및 웰빙 개선의 증거는 거의 없었다(Rodriguez-Jare~no et al. 2014).

In Europe, implementation of the European Working Time Directive in 1998 severely reduced the working hours of physicians in training (Datta and Davies 2014), with mixed reactions from the medical community (Maisonneuve et al. 2014), indications of a negative impact on training, particularly in surgical specialties (Hopmans et al. 2015), and little evidence of improvement in trainee working conditions and well-being (Rodriguez-Jare~no et al. 2014).

현재 [학습 환경 평가]는 (미국 뿐만 아니라 국제적으로도) accreditor들은 학습자와 교수자의 학습환경에 대한 인식을 수집하는 중요하고, 민감하며, 타당한 도구로 사용중이다. 

• 학부 의료 교육(LCME 2018; Mavis et al. 2014; Lockwood et al. 2004)에서도, 

• 미국 대학원 의료 교육을 위한 인증 기관(ACGME)에서도(Holt et al. 2018; Ibrahim et al. 2014). 

Assessments of the learning environment currently are used by accreditors 

• in undergraduate medical education in the United States and Canada (LCME 2018; Mavis et al. 2014; Lockwood et al. 2004) and 

• by the US accreditation body for postgraduate medical education (the Accreditation Council for Graduate Medical Education)

 as an important, sensitive and valid tool to collect learners’ and teachers’ perception of the learning environment in the US and internationally (Holt et al. 2018; Ibrahim et al. 2014). 

학습환경에 대한 평가 결과는 인증과 프로그램 개선을 위해 내부적으로 사용된다. 2013년 미국 PGME에서 새로운 인증 시스템을 시작했을 때, 여기에는 프로그램 연수생을 위한 연간 데이터 검사에 CLE의 학습자 및 교수진 평가와 CLER 프로그램을 통한 CLE의 전용 검토가 포함되었다(Wagner et al. 2016; Co et al. 2018; Weiss et al. 2018).

The results are used in accreditation and internally for program improvement. When the US accreditation postgraduate body for medical education launched a new accreditation system in 2013, this included both learner and teaching faculty assessments of the CLE in annual data screening for programs trainees, and a dedicated review of the CLE through the Clinical Learning Environment Review (CLER) program (Wagner et al. 2016; Co et al. 2018; Weiss et al. 2018).

학습환경에 관해 남은 문제들

Current challenges in the learning environment

국가 이해관계자 합의 문서는 과밀 임상 환경, 인력 부족 및 서비스 압력, 임상 작업 부하를 CLE의 학습 장벽으로 식별했다(Kilty et al. 2017). 다른 연구와 일관되게, 개선의 관점에서 가장 어려운 영역으로 확인된 영역은 "조직과 업무 조건"과 "환자 치료 중 상급 의사와 함께 배우는 시간"이었다(Kilty et al. 2017). 영국의 바와-가르바 사건은 이것의 뼈아픈 예다. 이 사례와 이와 유사한 일반적인 관찰은 "서비스 압력이 학습 기회에 영향을 미쳐서, 인지 과부하를 일으키고, 그 결과 물리적 공간에 대한 제약을 통해 성찰과 토론 시간을 제한한다"라는 가설을 추가로 뒷받침한다(Kilty et al., 2017, 페이지 8).

A national stakeholder consensus document identified overcrowded clinical environments, understaffing and service pressures and clinical workload as barriers to learning in the CLE (Kilty et al. 2017). Consistent with other studies, the domains identified as most challenging from an improvement perspective were the “organization and conditions of work” and “time to learn with senior doctors during patient care” (Kilty et al. 2017). The Bawa-Garba case in the United Kingdom is a poignant example of this (Vaughan 2018). This case and similar general observations further support the hypothesis that “service pressures impact opportunities to learn, resulting in cognitive overload, limiting time to reflect and discuss and through constraints on physical space” (Kilty et al. 2017, p. 8).

Macy Foundation은 범위 지정 검토를 의뢰하여 CLE를 네 가지 핵심 요소(개인, 사회, 물리 및 가상, 조직)로 디구성하는 개념 모델을 도입했다. 또한 상당한 학문적 노력에도 불구하고 임상학습 환경을 탐구한 연구에는 개념적 명확성이 결여되어 있음을 강조하였다(Gruppen et al. 2018).

The Macy Foundation commissioned a scoping review introduced a conceptual model that deconstructed the CLE into four central components (personal, social, physical and virtual, and organizational). It also highlighted that, despite considerable academic efforts, there is a lack of conceptual clarity in studies that have explored the clinical learning environment (Gruppen et al. 2018).

에비뉴 프레임워크 소개

Introducing the avenues framework

. The model approaches the CLE through six different lenses, which we have termed “avenues”  for this exploration (Figure 2)

To examine how different academic fields and foci haveinformed the study of the CLE, in Table 

Conclusions

Gruppen L, Irby D, Durning, Maggio L. 2018. Interventions designed to improve the learning environment in the health professions: a scoping review. AMEE MedEd Pub. 7:73.

Weiss KB, Co JPT, Bagian JP. 2018. Challenges and opportunities in the 6 focus areas: CLER national report of findings 2018. J Grad Med Educ. 10:25–48.

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Med Teach. 2019 Mar 17:1-7. doi: 10.1080/0142159X.2019.1566601. [Epub ahead of print]

The clinical learning environment.

Nordquist J1,2, Hall J3, Caverzagie K4, Snell L5,6, Chan MK7, Thoma B8, Razack S5, Philibert I9.

Author information

1

a Department of Medicine (Huddinge) , Karolinska Institutet , Stockholm , Sweden.

2

b Department of Research and Education , Karolinska University Hospital , Stockholm , Sweden.

3

c Department of Obstetrics and Gynecology , Queen's University , Kingston , Canada.

4

d Internal Medicine , University of Nebraska Medical Center , Omaha , NE , USA.

5

e Medicine , McGill University , Montreal , Canada.

6

f Royal College of Physicians and Surgeons of Canada , Ottawa , Canada.

7

g University of Manitoba , Winnipeg , Canada.

8

h University of Saskatchewan , Saskatoon , Canada.

9

i Accreditation Council of Graduate Medical Education , Chicago , IL , USA.

Abstract

Learning in a clinical context is foundational in the training of health professionals; there is simply no alternative. The subject of the clinicallearning environment (CLE) is at the forefront of discussions. In this introduction to a themed issue on the CLE, we present an expanded conceptual model that approaches the CLE through six different lenses, termed "avenues:" architectural, digital, diversity and inclusion, education, psychological, and sociocultural, with each avenue represented by a paper. The aim is to facilitate dialog around the contributions of different academic disciplines to research on the CLE. Collectively the papers highlight the overlap between the various "avenues" in how they influence each other, and how they collectively have shaped the work to understand and improve the CLE. The expectation is that the various avenues can add to existing knowledge and create new ideas for interventions to improve the clinical learning environment across nations for learners and teachers with the ultimate aim of improving patient care. Research and efforts to improve the CLE are critical to learning, professional socialization and well-being for trainees as they learn and participate in patient care, and to the quality of care they will deliver over decades of practice after graduation.

PMID:

 

30880530

 

DOI:

 

10.1080/0142159X.2019.1566601