의사소통 (스킬) 교육의 센스와 넌센스 (Patient Educ Couns. 2021)

의사소통 (스킬) 교육의 센스와 넌센스 (Patient Educ Couns. 2021)
The sense and nonsense of communication (skills) teaching - reflections from a parent and educator 

Anne de la Croix1

병원의 소아과 병동. 저는 심각한 발달 지연을 겪고 있는 제 1살짜리 아들을 진찰해 줄 신경과 의사를 초조하게 기다리고 있습니다. 신경과 의사가 5~6명의 수련생을 옆에 두고 들어옵니다. 그는 나에게 작은 인사말을 건네고, 연습생들에게 자신의 연구 결과를 보고하며 내 아이에게 집중한다. 신체검사 후 신경과 의사가 아들의 이름을 불러달라고 합니다. 저는 방구석에서 순종적으로 그렇게 합니다. 아이가 제 목소리에 반응하지 않았다. 이럴 줄 알았어. 제 아들과 저 사이의 연락과 유대감이 부족해서 매우 화가 났습니다. 아직도 나를 등지고 있는 신경과 의사는 그의 훈련생들에게 말한다: '봐, 엄마의 목소리에 전혀 반응이 없어. 이거 적어놨어? 그는 나를 쳐다보지 않는다. 공감대도, 연결도, 소통도, 공감도 없다. 얼마 지나지 않아 그가 내게 작별인사를 건네자 수련 중인 젊은 의사단이 방을 떠난다. 그들 중 한 명이 동정 어린 눈빛으로 나를 바라본다. 나는 아들을 안고 슬퍼요.
A pediatric ward of a hospital. I am nervously waiting for a neurologist who will examine my 1-year-old baby boy who has severe developmental delays. The neurologist walks in, with 5 or 6 trainees by his side. He nods a small greeting to me, and focuses on my child, reporting his findings to the group of trainees. The neurologist, after a physical examination, asks me to call out my son’s name. I obediently do so, from the corner of the room. My child does not respond to my voice. I knew this would happen. The lack of contact and bonding between my son and me has been extremely upsetting. The neurologist, still with his back towards me, says to his trainees: ‘See, no response to mother’s voice at all. Did you write this down?’. He does not look at me. There is no rapport, no connection, no communication, no empathy. Shortly after that, he gives me a nod goodbye and the troupe of young doctors in training leaves the room. One of them looks at me with sympathy. I pick up my son and feel sad.

이틀 뒤에. 의과대학 교습실. 저는 12명의 어린 의대생들에게 의사소통과 직업적 행동에 대해 가르치고 있습니다. 저는 이 중요한 주제들에 대해 그들과 대화해야 한다는 새로운 긴박감을 느낍니다. 그들은 관절염과 우울증을 모두 가진 환자를 연기하는 배우와 함께 역사를 연습한다. 공감, 환자의 관점, 연결고리에 대해 이야기하는 좋은 세션입니다. 

수업이 끝날 때, 저는 이렇게 묻습니다: '이 세션을 마치기 전에 할 말이나 질문이 있나요?' '

몇 명이 손을 든다: 공감이 되는 문장을 다시 한 번 말씀해 주시겠어요, 검사에 유용할 것입니다.' '환자 자신의 생각과 인식에 대한 질문은 건너뛰어도 괜찮을까요? 그것은 너무 많은 시간이 걸리고, 우리는 시험에서 8분밖에 받지 못합니다.' 그들은 

Two days later. A teaching room at a medical school. I am teaching twelve young medical students about communication and professional behavior. I feel a renewed sense of urgency to talk with them about these important topics. They practice history taking on an actor who portrays a patient with both arthritis and depression. It is a good session in which we talk about empathy, the patient’s perspective, and making a connection.

At the end of class, I ask: ‘Do you have anything to say or ask before we close this session?’

A few hands go up: ‘Could you repeat the sentence that shows empathy, it will be useful for the exam,’ ‘Is it ok to skip the question about the patient’s own ideas and perceptions? It takes so much time, and we only get 8 minutes in the exam.’

배우고 싶어하고 의사가 되기를 열망하지만, 무엇보다도, 학생은 다음 시험에 합격하기를 열망한다. 나는 세션을 닫고 슬픕니다.

They are eager to learn, eager to become doctors, but most of all: eager to pass their next exam. I close the session and feel sad.

이 두 가지 상호작용은 모두 8년 전에 일어났으며, 제 사생활과 직장 생활 사이의 불협화음의 시기를 나타냅니다.
Both these interactions took place eight years ago and represent a period of dissonance between my private life and professional life.

엄마로서 신경과 의사와의 상호 작용에 대한 기억이 아직도 아픕니다. 그때 내가 원했던 것은 그들이 나를 경청하고 나를 바라봐주는 것이었다. 저는 올바른 진단과 치료를 찾는 의사의 팀메이트가 되고 싶었습니다. 저는 제 아들에 대한 생각과 관찰을 공유하고 싶었습니다. 그리고 의사가 내가 걱정하거나 겁먹거나 슬퍼해도 괜찮다고 말해주길 바랐어 위에서 만난 신경과 의사는 감정, 두려움, 걱정, 혹은 나와 함께 할 수 있는 파트너쉽에 대해 잊어버린 것 같았다.
As a mother, the memory of the interaction with the neurologist still stings. What I wanted at the time was to be heard and seen. I wanted to be the physician’s team-mate in the search for the right diagnosis and care. I wanted to share my ideas and observations about my son. And I wanted the doctor to say it was okay for me to be worried, scared, or sad. The neurologist in the encounter above seemed to have forgotten about emotions, about fears and worries, or about a possible partnership with me.

전문직으로서, 저는 의과대학에서 젊고 의욕적인 학생들과 함께 일했습니다. 의대생들에게 의사소통 기술을 가르치는 교사가 되고 의료 분야에서 공감을 이끌어내는 것은 가치 있는 직업처럼 느껴졌습니다. 저는 학생들이 의사-환자 상호 작용의 핵심이 무엇인지 알게 되기를 바랐습니다: 인정, 접촉, 존중, 호기심, 이해, 동반자 관계. 하지만 나는 나의 의사소통 능력이 의대생들의 정서적 예민한 면을 발전시키는데 늘 기여하지는 못함을 것을 알게 되었습니다.
As a professional, I worked at a medical school, with young and driven medical students. Being a communication skills teacher to medical students and encouraging empathy in healthcare felt like a valuable career. I hoped to make the students aware of what lies at the core of doctor-patient interaction: acknowledgment, contact, respect, curiosity, understanding, a sense of partnership. But I noticed that my communication skills teaching did not always manage to contribute to the development of the emotionally sensitive side of medical students.

위에서 설명한 사건들을 겪으면서, 저는 의사소통의 일반적인 방식에 대해 의구심을 품기 시작했습니다. 나는 내가 가르친 학생들에게 진급progress에 필요한 행동을 보여주는데 집중했고, 나는 종종 임상 실습의 인간적인 측면을 잊어버렸다. 마치 위에서 설명한 신경과 의사처럼 말이다. 나는 학생들이 시험에 합격하기 위해 '올바른 말'을 할 줄 안다는 것을 발견했다. 나는 '공감'이 다면적인 인간 경험에서 얕은 체크박스 운동으로 변화된 교육문화를 경험했다. 오해하지 마세요: 구체적인 행동을 배우는 것은 상담을 관리하는 데 매우 유용할 수 있습니다. 그러나 의사소통 교육이 근본적인 도덕성을 가지고 있지 않고 행동 대본의 범위로 '숙련'되면, 그것은 의미를 잃는다. 행동에 지나치게 집중하는 것은 근본적인 생각과 감정을 다루지 않고 '트릭'을 수행하는 것으로 이어진다.
During the events described above, I started doubting the way communication is generally taught. Students I taught were focused on showing desired behavior in order to progress successfully, during which they sometimes forgot the humane side of clinical practice – much like the neurologist described above. I discovered that students knew how to say ‘the right things’ to pass the test. I experienced an educational culture in which ‘empathy’ was transformed from multifaceted meaningful human experience into a shallow tick-box exercise. Don’t get me wrong: learning specific behaviors can be very useful for managing a consultation. But when communication teaching has no underlying morality and is ‘skillified’ into a range of behavioral scripts, it loses its meaning. An overfocus on behavior leads to performing ‘tricks’ without addressing underlying thoughts and feelings.

제가 겪었던 또 다른 문제는 저의 가르침이 주로 임상 전 교육과정에, 교실 중심의 가르침으로 둘러싸인 매우 '학교 같은' 환경에서 이루어졌다는 것입니다. 그러나 학생들은 모두 진정한 배움이 시작되는 장소인 병원과 의사들을 학수고대하는 것 같았다. 학생들이 사무원이 되어 미래의 직장에서 배우고 있을 때, 나는 그들이 클리닉의 문화에 몰입하고 사회화되는 것을 보았다. 저는 그들이 직장에서 배운 교훈이 제가 학교 같은 환경에서 비임상사로서 가르치던 것보다 더 영향력이 있다는 것을 알게 되었습니다. 실습 의사인 그들의 선생님은 의사 소통에서 훌륭한 역할 모델이 될 수 있고 학생들이 소통하고 공감하는 의사가 되도록 이끌 수 있다. 반대로 롤모델이 위에서 설명한 신경과 의사와 유사하다면, 인간적 접촉은 부차적이라고 학생들에게 가르칠 수 있다.

Another issue I had was that my teaching mainly took place in the pre-clinical curriculum, in a very ‘school-like’ surrounding with classroom based teaching. But the students all seemed to look forward to the place where the real learning would start: in hospital, with doctors. Once students became clerks and were learning in their future workplace, I saw them being immersed and socialized in the culture of the clinic. I noticed that the lessons they learnt in the workplace were more impactful than those that I used to teach, as a non-clinician in a school-like environment. Their teachers, practicing physicians, could be excellent role models in communication and could steer students towards becoming communicative and empathic doctors. Alternatively, the role models could be similar to the neurologist described above and implictly teach students that human contact is of secondary importance.

한마디로, 나는 미래의 의료 전문인력 양성에 의미 있는 영향을 미치지 못하고 있다고 느꼈고, 그래서 의과대학 교육에서 벗어나기로 결심했다.
In short: it felt as if I was unable to make a meaningful impact on the development of future health care professionals and decided to move away from teaching at medical school.

내 아들은 나이를 먹었다. 그는 희귀한 증후군이라는 진단을 받았다. 복잡한 보살핌을 필요로 하는 아이를 갖는 것에 수반되는 감정들을 처리했습니다. 나는 지지와 보살핌을 받았다. 둘째를 낳아 축복받았다 저는 '특별한 도움이 필요한 엄마'로서의 제 역할을 찾았고, 제 아들을 둘러싼 보호자들과 의료 전문가들의 증가하는 네트워크를 탐색하는 방법을 배웠습니다. 그리고 저는 교육연구가, 교사 트레이너, 교육과정 혁신 자문가라는 새로운 학문적 역할을 찾았습니다. 그러다가, 저는 전혀 원활하게 실행되지 않는 '소통 능력' 모듈을 개편해달라는 요청을 받았습니다. 학생들은 시험에 합격하는 데만 집중했는데, 이것은 그들이 '쓸모가 없다'고 여기는 성찰적인 논술이었다. 수업에서는 서로에 대한 의사소통 연습을 했는데, 이는 '무익하다'와 '지루하다'는 평가를 받았다. 그래서 저는 오래된 딜레마에 봉착했습니다. 의미있는 의사소통 교육을 어떻게 하면 학생들이 공감하고 소통하는 전문가로 성장하는데 영향을 미칠 수 있을까?
My son grew older. He got a diagnosis – a rare syndrome. I processed the emotions that come with having a child with complex care needs. I received support and care. I was blessed with a second (healthy) child. I found my role as a ‘special needs mother’ and learnt how to navigate the growing network of carers and health care professionals around my son. And I found a new academic role as educational researcher, teacher trainer, and advisor for curriculum innovations. In this role, I was asked to revise a ‘Communication Skills’ module, which did not run smoothly at all, with problems that I remembered from my time as a teacher. Students were only focused on passing the test, which was a reflective essay they considered to be ‘useless’. In the classes, they practiced communication on each other, which was evaluated as ‘pointless’ and ‘boring’. So there I was, confronted with an old dilemma: how to create meaningful communication education, that has an impact on the students’ development into empathic and communicative professionals?

그때가 제가 저의 직업적인 역할과 저의 개인적인 역사를 결합하기로 결심한 때입니다. 복잡한 돌봄을 필요로하는 가족의 여정을 들을 수 있다면, 복잡한 돌봄 네트워크 관리에 수반되는 정서적 롤러코스터를 학생들이 느낄 수 있다면 얼마나 값질까. 복잡한 돌봄이 필요한 아이들의 부모들에게 다가가 보니 엄청난 추진력과 열정이 느껴졌다. 그 모듈은 큰 성공을 거두었고 현재 다른 커리큘럼에서 시행되고 있다. 저는 환자의 의료 교육 참여가 미래라고 믿게 되었습니다. 학생들이 실제의, 살아 있는 경험에 귀를 기울이게 하고, 환자와 유대감을 형성하고, 환자의 여정을 따르도록 하는 것입니다. 학생들에게 감정에 대해 가르치려고 할 때, 우리는 분명히 순수하게 인지적이고 기술에 기반을 둔 경험보다는 변화적이고 중요한 학습 경험을 제공할 필요가 있다.
That is when I decided to combine my professional role and my personal history. How valuable would it be for students to listen to the journey of a family with complex care needs, to feel the emotional rollercoaster that comes with managing a complex network of care? I approached parents of children with complex care needs, and was met with an enormous drive and enthusiasm. The module was a great success and is currently being implemented in different curricula. I have come to believe that patient participation in medical education is the future: getting students to listen to real, lived experiences, to form bonds with patients, to follow the patient journey. When trying to teach students about emotions, surely we need to offer transformative and significant learning experiences rather than purely cognitive and skills-based ones.

사람들이 만나서 서로의 이야기를 진실로 들어줄 때 배움이 이루어진다는 것을 믿자. 의대생들에게 딱 붙어서 떨어지지 않으며, 젊은 의사로서의 모습을 갖추게 해줄 풍부한 학습 경험을 제공함으로써, 의대생들의 자연스러운 호기심을 키워주자. 다음 검사가 무엇인지보다 무엇이 옳은 일일지를 더 신경을 쓰는 젊은 의사 말이다. 신경과 과장과 달리, 구석에 있는 걱정스러운 부모에게 말을 걸 수 있는 젊은 의사들 말이다.
Let us trust that learning will take place when people meet and truly listen to each other’s stories. Let us nourish the natural curiosity of medical students by offering them rich learning experiences that are likely to stick with them and shape them as they develop into young doctors. Young doctors who care less about what will be asked at the next test and more about doing the right thing. Young doctors who might talk to the worried parent in the corner when their neurologist supervisor does not.

8년 후. 큰 대학의 교무실. 저는 열두 명의 학생들에게 의사소통에 대해 가르치고 있습니다. 교실에 손님이 오셨습니다: 제 아들과 같은 탁아소에 다니는 심각한 특수 장애를 가진 아이의 부모입니다. 학생들은 실제 인물과 상호작용하는 것에 대해 긴장하고, 평가를 받지 않더라도 잘하고 싶어한다. 그들은 그들이 원하는 모든 것을 물어보고 임신과 출생, 진단으로의 여정, 아이의 발달, 형제자매에게 미치는 영향, 진단을 받아들이는 데 관련된 감정, 아이를 둘러싼 돌봄 네트워크, 다양한 치료 및 치료 등에 대해 질문하도록 초대되었다. 그들은 철저하고 호기심 있게 부모의 인생 세계를 탐험합니다. 한 학생이 학부모를 울리는 질문을 해 그룹 내에서 눈에 보이는 불편함을 유발한다. 저는 학생들이 왜 감정이 우리를 불편하게 만드는지 탐구하도록 초대합니다. 학생들은 부모들에게 감정적인 순간 후에 무엇을 말하거나 했어야 했는지 묻습니다. 우리는 공감이라고 부르지 않고 공감에 대해 토론하고, 우리 모두는 상호작용의 영향을 느낍니다. 나중에 모든 학생들이 부모님께 감사드리고, 부모님들도 감사 드려요. 나는 세션을 닫고 만족감을 느낀다.

Eight years later. A teaching room at a big university. I am teaching twelve students about communication. We have a guest in the classroom: the parent of a child with severe special needs who goes to the same day care center as my son. The students are nervous about interacting with a real person, and want to do well, even though they won’t be assessed. They were invited to ask anything they want and ask questions about pregnancy and birth, the journey towards diagnosis, the development of the child, the impact on the siblings, the emotions involved in accepting the diagnosis, the network of care around the child, the different types of therapy and treatment, etc. They thoroughly and curiously explore the lifeworld of the parent. One student asks a question that makes the parent tear up, causing visible discomfort in the group. I invite students to explore why emotion makes us uncomfortable. The students ask the parent what they should have said or done after the emotional moment. We discuss empathy without calling it empathy, and we all feel the impact of the interaction. All students thank the parent afterwards, and the parent thanks them. I close the session and feel fulfilled.

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Patient Educ Couns. 2021 Dec 7;S0738-3991(21)00781-3.

 doi: 10.1016/j.pec.2021.12.004. Online ahead of print.

The sense and nonsense of communication (skills) teaching - Reflections from a patient and educator

Anne de la Croix 1

Affiliations collapse

Affiliation

• 1Amsterdam UMC, Research in Education, Faculty of Medicine, Vrije Universiteit Amsterdam, The Netherlands. Electronic address: a.delacroix@amsterdamumc.nl.

• PMID: 34895960
• DOI: 10.1016/j.pec.2021.12.004