학부의학교육에서 장애 학생의 경험(Med Teach, 2022)

학부의학교육에서 장애 학생의 경험(Med Teach, 2022)
Experiences of disabled students in undergraduate medical education
Elda de Oliveiraa, Rafaela Gonc¸alves Dantasb, Giovanna Araujo Amaralb , Renata Rocha Barreto Giaxac and A
ecio Fl
avio Teixeira de G
oisd  

 

서론
Introduction

신체, 시각, 청각 장애를 가진 사람들을 대학 의학 교육에 포함시키는 것은 동시에 논란이 되는 문제이지만 아직 거의 논의되지 않은 문제이다. 미국에서 1990년 미국 장애인법(Americanese Disability Act, ADA)은 모든 교육 기관이 장애인을 위한 합리적인 편의시설accomodation을 제공하도록 규정하고 있다(Eickmeyer et al. 2012). 그러나 이러한 이론적 법적 보호에도 불구하고 연구에 따르면 실제로 PwD는 여전히 의학에 포함되기 위해 애쓰고 있다. 2019년 87개의 미국 의대에서 수행된 유병률 연구(Meeks et al. 2019)는 2016년에 비해 69% 증가한 4.6%의 장애 학생을 지적했다. 미국 질병통제센터(Centers for Disease Control and Prevention 2018)에 따르면, PwD의 존재는 상당한 증가에도 불구하고, 전체 인구에서 PwD의 비율과 비교했을 때, 학부생들의 장애 비율은 여전히 낮다.
The inclusion of people with physical, visual and/or hearing disabilities in undergraduate Medical education is, at the same time, a controversial issue and yet one that is little discussed. In the United States, the Americans with Disabilities Act (ADA) of 1990 mandates that all educational institutions provide reasonable accommodations for people with disabilities (PwD) (Eickmeyer et al. 2012). However, in spite of this theoretical legal protection, studies show that, in practice, PwD are still struggling to be included in Medicine. A prevalence study conducted in 87 American medical schools in 2019 (Meeks et al. 2019) pointed to a percentage of 4.6% of students with disabilities, which represented an increase of 69% when compared to 2016. Despite the considerable growth in the presence of PwD, the percentage of students with disabilities in undergraduate medicine is still low when compared to the percentage of PwD in the overall population, which is about 26% in the United States, according to the Center for Disease Control (Centers for Disease Control and Prevention 2018).

이는 접근 불가능한 물리적 구조, 입학 위원회로부터의 차별, 그리고 학생들이 의학 과정의 마지막에 어떤 전공을 선택할 수 있어야 한다는 의료 문화에 대한 믿음을 포함하는 inclusion을 방해하는 요소들의 존재를 지적한다(Mercer et al. 2003). 이러한 믿음은 PwD를 포함하는 것을 중심으로 한 모든 대화를 핫버튼 이슈로 만든다. 포용적 교육의 또 다른 장애물은 PwD의 가시성 부족이다. 미국의 75개 의과대학(DeLisa and Thomas 2005)을 대상으로 실시한 연구에 따르면, 이들 중 36개(48%)가 장애학생을 이전에 입학시켰다고 보고했음에도 불구하고 교과과정에서 장애문제를 다루지 않았다. 
This points to the existence of factors that hinder inclusion, which include inaccessible physical structures, discrimination from admissions committees, and a belief in medical culture that students must be ‘undifferentiated’, therefore able to opt for any specialty at the end of the medical course, and physically ‘perfect’ (Mercer et al. 2003). This belief makes any conversation centered around inclusion of PwD a hot-button issue. Another hindrance to inclusive education is the lack of visibility of PwD. A study conducted in 75 American medical schools (DeLisa and Thomas 2005) showed that 36 of them (48%) did not address the issue of disability in their curriculum, even though some reported that they had previously admitted disabled students.

또한 교육 접근성access은 장애학생의 교육 진입뿐만 아니라 이 공간에서의 영속성은 물론, 그들이 받는 교육의 효과도 고려해야 하는데, 이는 그들의 특별한 요구에 맞게 조정되어야 한다. 이러한 믿음은 [신체의 유기적 또는 구조적 기능 장애]와 [사회 활동을 수행하고 참여하기 위한 제한] 사이의 연결부위에서 장애가 발생하며, 여기에 사회 참여에 촉진제 또는 장벽을 부과하는 환경적 요인도 있다.(Cieza et al.. 2018).
In addition, access to education does not concern only the entry of disabled students in higher education, but also their permanence in this space, as well as the effectiveness of the education they receive, which must be adapted to their special needs. This belief is in line with the biopsychosocial view of disability, which states that disability results from the articulation between organic or structural dysfunction of the body and the limitation to perform and participate in social activities, plus environmental factors that impose facilitators or barriers to social participation (Cieza et al. 2018).

본 연구의 저자들은 장애가 있는 의대 학생들의 경험을 결정하는 촉진제와 장벽을 식별하고 가능한 포괄적인 제도적 태도와 정책을 제안하기 위해 브라질 전통 의대 학생들을 인터뷰했다. 우리는 이 모집단을 더 잘 이해하기 위해 인터뷰를 신중하게 분석했습니다.
To identify the facilitators and barriers that determine the experience of medical students with disabilities and to propose possible inclusive institutional attitudes and policies, the authors of the present study interviewed students with disabilities from a traditional Brazilian medical school. We carefully analyzed the interviews, seeking to better understand this population.

자재와 방법
Materials and methods

우리는 브라질의 한 전통 의과대학에서 온 장애 의대생들과 함께 탐구적인 정성 연구를 수행했다. 연구 참가자의 포함 기준은 2020년 현재 부속 기관의 학부 의학 과정의 어느 단계에 등록한 학생으로서 신체, 시각 및/또는 청각 장애가 있는 학생이다. 제외 기준은 다른 기관에서 신체, 시각 및/또는 청각 장애가 있는 의대생, 정신, 학습 및/또는 발달 장애가 있는 학생이었다. 
We conducted an exploratory qualitative research with disabled medical students from a traditional medical school in Brazil. The inclusion criteria for research participants were: students enrolled in any stage of the undergraduate medical course in the affiliate institution as of 2020, who have physical, visual and/or hearing disabilities. The exclusion criteria were: medical students with physical, visual and/or hearing disabilities from other institutions, students with mental, learning and/or developmental disabilities.

참가자 선택을 위해 기준 체인을 사용하는 비확률 샘플링의 한 형태인 스노우볼 샘플링 기법을 사용했다(Heckathorn 2011). 우리는 프로필에 맞는 학생들을 소개한 몇몇 인터뷰 대상자들과 접촉했다. 앞서 언급한 기관 및 강좌의 장애 학생 수가 제한되어 있어 현재 연구를 위해 이 기법을 선택했습니다. 
For the selection of participants, we used the snowball sampling technique, a form of non-probability sampling that uses reference chains (Heckathorn 2011). We made contact with some interviewees, who referred more students who fit the profile, and so on. We chose this technique for the current research due to the restricted number of disabled students in the aforementioned institution and course.

참가자들은 사회재생산지수(SRI)에 따라 그룹으로 나눌 수 있는 사회경제적 설문지에 답했습니다. 그룹 I은 사회경제적 안정성이 더 높은 그룹이고, 그룹 II, III, IV는 더 큰 불안정성에 직면한다.
The participants answered a socioeconomic questionnaire that allowed them to be divided into groups, according to the Social Reproduction Index (SRI). Group I is the group with greater socioeconomic stability, while groups II, III, and IV face greater precariousness (Trapé 2011).

이후 각 참가자를 대상으로 개별 심층면접을 진행했는데, 이들이 의학교육 경험을 자유롭게 이야기할 수 있었다. 인터뷰 대상자들이 그들의 경험에 기인하는 의미를 식별하기 위해, 우리는 안내 대본에 제시된 공개 질문을 사용했다. 참가자가 개발한 서사에 따라 자연스럽게 새로운 질문이 추가되어 각 학생의 경험이 최대한 글로벌하게 고려되었다. 이러한 유형의 인터뷰는 질적 연구를 위해 오랫동안 권장되어 왔다.
After that, we conducted an individual in-depth interview with each participant, in which they were able to talk freely about their experiences in Medical education. To identify the meanings that the interviewees attributed to their experiences, we used open questions, present in a guiding script. Depending on the narrative developed by the participant, new questions were spontaneously added, so that each student's experience was contemplated in the most global way possible. This type of interviewing has been long recommended for qualitative research (Britten 1995).

인터뷰는 구글 미츠 플랫폼을 통해 이뤄졌다. 모든 인터뷰는 데이터 분석을 위해 완전히 기록되고 기록되었다. 3명의 다른 연구자들에 의한 성적표 분석은 학생들의 서술에서 반복되는 주제를 식별할 수 있게 해주었다. 1964년 헬싱키 선언에 제시된 모든 연구 윤리 규범들이 이 조사에서 지켜졌다. 모든 참가자는 사전 동의서에 서명했습니다. 그 프로젝트는 제휴 기관의 윤리 위원회에 의해 승인되었다.
The interviews were conducted through the Google Meets platform. All interviews were recorded and transcribed in full for the purpose of data analysis. The analysis of the transcripts by 3 different researchers allowed the identification of recurring themes in the students' narratives.

All research ethics precepts present in the Declaration of Helsinki (1964) were followed in this investigation. All participants signed the Informed Consent Form. The project was approved by the affiliate institution's ethical committee.

결과.
Results

여기에 S1에서 S9라는 코드명으로 지정된 9명의 학생이 연구에 참여했습니다. 참가자 중 2명은 학점 미달로 학부 의과 1학년(S4, S6)을 통과하지 못했다. SRI의 적용은 뚜렷한 사회적 조건을 가진 두 집단(GI와 GII)을 식별했다. 면접 대상 학생 중 6명(66.6%)은 GI, 3명은 GII(33.4%)로 분류됐다. 따라서 참여자 대다수가 높은 사회경제적 점수를 보여 안정적인 근로·생활 여건을 제시했다. 참가자들의 사회경제적 프로파일은 표 1에서 확인할 수 있다.
Nine students participated in the study, designated here by the codenames S1 to S9. Two of the participants did not pass their first year of the undergraduate medical course (S4 and S6) due to insufficient grades. The application of the SRI identified two groups with distinct social conditions (GI and GII). Six of the interviewed students (66.6%) were classified in GI and 3 were classified in GII (33.4%). Therefore, the majority of the participants showed high socioeconomic scores, presenting stable working and living conditions. The socioeconomic profile of the participants can be found in Table 1.

다음 주제는 심층 인터뷰 동안 참가자들의 서술에서 파악된 주요 주제였다.
The following themes were the main subject matters apprehended from the participants' narratives during their in-depth interviews.

주제 1: 의학교육 진출
Theme 1: Entry into medical education

연구가 진행된 기관의 PwD 대학 입시는 affirmative action system 나 일반경쟁을 통해 이뤄질 수 있다. affirmative action system 는 학생들의 궤적에서 발생할 수 있는 불평등을 커버하는 것을 추구하지만, 장애가 있는 학생들이 자격을 얻기 위해서는 그들 모두가 충족시킬 수 없는 몇 가지 다른 요구 조건이 있다.
University admission for PwD in the institution where the research was conducted can occur through the affirmative action system or through general competition. The affirmative action system seeks to cover possible inequalities in the trajectory of students, but in order for the disabled students to qualify, there are several different requirements that not all of them could meet:

저는 장애 할당제를 통과하지 못했습니다. 왜냐하면 장애 할당제는 고등학교 때 공립학교에서 공부한 것과 같은 다른 조건들을 충족시켜야 하기 때문입니다. [S2]
I didn't get in through the disability quotas because they have other requirements that you have to fulfill, [such as] having studied in public school in high school. [S2]

학생들이 등록할 때, 그들은 그들이 의과대학에서 필요로 하는 가능한 적응에 대한 요청을 제출하기 위해 서면 양식을 받는다. 그러나 학생들은 그 과정이 실제로 어떤 것인지 알지 못하기 때문에 그들의 요구가 무엇인지 알지 못한다.
When students enroll, they receive a written form in order to put in requests for possible adaptations that they will need during Medical school. However, the students have no knowledge of what the course is actually like, and therefore they don't know what their needs will be:

그들은 우리에게 무엇이 필요한지 물어보는 종이를 준다. 의학 과정이 무엇인지를 등록하는 순간 제가 알고 있는 바로는, 저는 생각했습니다. 나는 아무것도 필요하지 않을 것 같은데, 그것은 사실이 아니었다. [S7]
They give us a paper [asking what] you will need. Of my knowledge at the moment registration of what the medical course is, I thought… I don't think I will need anything, which was not true. [S7]

장애학생의 대부분이 공립학교 출신이기 때문에, 장애 관련 문제 외에도, 그들 중 일부는 학업의 어려움과 관련된 포함 장벽을 보고했다.
Since most of the students with disabilities came from public schools, in addition to disability-related issues, some of them reported inclusion barriers related to academic difficulties:

저는 신체적인 한계 때문만이 아니라, 특히 최고의 학교에서 공부했던 반 친구들과 가까운 저의 낙후된 교육 문제 때문에 많은 어려움을 겪고 있습니다. [S9]
I have quite a bit of difficulty, not only [due to] physical limitation, but also because of the issue of my lagging education, […] especially close to my classmates, who studied in the best schools. [S9]

주제 2: 정체성과 사회화
Theme 2: Identity and socialization

학생들은 특정한 상황에서, 그들의 장애는 반 친구들과 선생님들에 의해 과소평가될 수 있으며, 이것은 부정적인 영향을 가져올 수 있다고 보고했다.
Students reported that, in certain situations, their disability can be underestimated by classmates and teachers, which can bring negative repercussions:

저는 듣기 거북한 표현을 여러 번 들었습니다. 여러분은 아무런 문제가 없고, 걸을 수 있고, 숨을 쉴 수 있고, 볼 수 있습니다. […] 누군가가 당신의 장애를 보고 '이것은 아무것도 아니다'라고 말할 때, 그들은 그것을 중요하지 않은 것으로 축소합니다. 그리고 당신은 그것이 중요하다는 것을 압니다. [S1]
I have heard several times [expressions] that hurt to hear: you don’t have any trouble, you can walk, you can breathe, you can see. […] when someone looks at your disability and says ‘this is nothing’ […] they reduce it to zero importance, and you know that it […] matters. [S1]

'방에 계신 분들은 제가 다른 모든 사람들과 함께 모든 것을 하는 것을 본 것 같아서 제가 적응할 필요가 있다는 것도 몰랐던 것 같습니다. 하지만 저는 장애가 존재하지 않는 것처럼 살고 싶지 않습니다.' [S2];
‘I think the people […] in the room didn't even know that I need to make some adaptations because I think they see me doing everything with everyone else […] but I don't want to live as if the disability didn't exist.’ [S2];

선생님들은 결코 나의 장애를 문제로 다루지 않았다. 그들은 항상 제 인생의 이 부분을 배제하려고 노력했고, 저는 반 친구들과의 관계에서 덜 포함되었다고 느꼈습니다. [S7]
The teachers never treated my disability as an issue. […] they always tried to just exclude this part of my life, [and] I felt less included in relation to my classmates. [S7]

또한 장애를 과소평가하지 않았지만, 부정적인 시각으로 강조한 불쾌한 사건들에 대한 보고도 있었다.
There were also some reports of unpleasant episodes in which disability was not underestimated, but highlighted in a negative light:

선생님은 우리가 그 절차를 어떻게 해야 하는지 설명해 주셨다. 제가 손을 제대로 놓지 않았는데 그가 농담으로 '팔이 삐뚤어진 것 같다'고 말했죠. 바로 그거야. 반경의 편차가 있어. [S1]
The teacher […] explained how we needed to do the procedure. I hadn't put [my hand] exactly in the right place […] and he said, jokingly, ‘it looks like you have a crooked arm’, and that’s exactly it, I have a deviation of the radius. [S1]

이러한 어려움에도 불구하고, 학생들은 일반적으로 그들의 반 친구들이 잘 받아들인다고 보고했다.
Despite these difficulties, students reported, in general, a good acceptance by their classmates:

대학 환경은 매우 환영할 만하다. 나는 항상 나를 도와준 친구들이 있었다. [S5]
The university environment is very welcoming […]. I always had friends that helped me. [S5]

저는 제 반 친구들이 저를 그렇게 많이 도와줄 거라고는 상상도 못했어요.
I never imagined that my classmates would help me so much. [S4]

우리 반 친구들은 환영하고 있다. 내가 장애를 가지고 있다는 이유로 동료들 중 누구도 나를 차별한 적이 없다. [S7]
My current classmates […] are welcoming. None of my colleagues have ever discriminated against me because I have a disability. [S7]

그러나 일부 사람들은 대학 생활에서 운동 경기와 대회에 참가하는 것이 힘들다는 것에 대해 다음과 같은 활동들은 신체적 능력에 집중되어 있기 때문이다.
However, some also reported anguish related to the difficulty of participating in athletic games and competitions in their university life, because these activities are focused on physical abilities:

그들은 매일 훈련하는데, 난 그럴 수 없어. [S3]
They train every day, and I can't do that. [S3]

체력적인 충격으로 참가를 못 하겠어요, 많이 뛰셔야 해요. […] 참여하고 싶었기 때문에 조금 슬픕니다. [S9]
I can't participate because of the physical impact, you have to run a lot. […] I get a little sad, because I wanted to participate. [S9]

주제 3: 선생님들
Theme 3: Teachers

의학 과정의 교수들 중 대부분은 특히 학부 교육을 시작할 때 학생들의 특별한 필요가 무엇인지를 알지 못한다.
Most of the professors in the medical course are not aware of the students' special needs, especially at the beginning of undergraduate education:

지금까지 의학교육을 하면서 저는 선생님이 장애를 가지고 있는 사람들을 알고 계시고, 이러한 사람들을 통합하거나 활동을 적응시키려고 노력하신 것을 본 적이 없습니다. […] 결코 선생님은 적극적으로 노력하지 않았다. [S3]
So far in my time in medical education I have never seen a teacher […] with a list of people that he knows that have a disability and he tried to integrate these people or adapt the activities. […] It was never a proactive effort of the teacher. [S3]

[…] 처음에는, 그들은 제 욕구의 범위와 장애 그 자체가 부과하는 한계들을 몰랐지만, 시간이 지나면서 이러한 한계들은 명백해졌습니다. [S5]
[…] in the beginning, they did not know the extent of my needs and the limitations that the disability itself imposes, but with time these limitations became explicit. [S5]

장애 학생과의 공존을 통해, 선생님들은 그들의 특별한 필요를 알게 되고, 많은 사람들은 특정한 강의나 활동을 적응시킴으로써 그들을 도우려고 노력한다.
Throughout the coexistence with the disabled students, teachers come to know their special needs, and many try to help them by adapting certain lectures or activities:

나는 시험에 무엇이 나오는지 볼 수 없었다. […] 그들이 그것을 깨달았을 때, 그들은 나에게 더 큰 글꼴의 테스트를 제안했고, 그것은 나에게 큰 도움이 되었습니다. 그들은 또한 내가 내 공책에 있는 시험을 볼 수 있도록 허락해줬어. 한 선생님이 수업 전에 확대된 슬라이드 발표를 보내 주셔. [S4]
I couldn't see what was on the test. […]. When they realized it, they offered me tests with a bigger font, which helped me a lot. They also allowed me to take the exam in my notebook. One teacher sends me enlarged slide presentations before the classes. [S4]

실제 시나리오에서는 심폐소생술이 있었고, 마스크팩을 들고 있는 동시에 인공호흡기를 들고 있어야 했습니다. 두 가지를 동시에 할 수는 없었지만, 옆에 있는 선생님들이 동료에게 도움을 요청했고 모든 것이 잘 해결되었습니다. [S2]
In the practical scenarios […] we had cardiopulmonary resuscitation and […] I had to hold the ventilation device at the same time as I was holding the face mask, I couldn't do both at the same time, but the teachers next to me asked a colleague to help me and everything worked out fine. [S2]

나는 항상 해부학 선생님의 도움을 받았다. 그는 실험실의 테이블에서 해부학적 신체 부위를 꺼내서 제가 공부할 수 있도록 더 가까이 가져왔습니다. [S5]
I always had the help of the anatomy teacher. He took the [anatomic] body parts from the table at the lab and brought them closer to me so I could study. [S5]

주제 4: 강의
Theme 4: Lectures

의학 과정에서의 강의의 긴 시간과 강의가 이루어지는 공간은 일부 학생들에게 문제를 야기했다.
The long duration of the lectures in the medical course and the space in which they take place caused problems for some students:

수업 중에 통증이 있어서 다리를 뻗을 수가 없어요. 수업은 더 짧을 수 있고, 방은 더 많은 공간을 가질 수 있다. 나는 움직여야 한다. [S3]
The pain gets in the way during classes, […] I can't stretch my legs […]. The classes could be shorter, and the room could have more space. I have to get up to […] move around. [S3]

강당의 위치가 다르기 때문에 학생들이 강의 사이에 걸어 들어가야 하는 긴 길은 또한 장애 학생들을 위한 어려움으로 제시된다.
The long way students have to walk in between lectures due to the different locations of the auditoriums also presents itself as a difficulty for students with disabilities.

캠퍼스가 너무 넓어서 반에서 반으로 바꾸려면 몇 군데 길을 건너야 한다. 휠체어가 인도로 넘어지면서 일어나기 위해 도움이 필요한 상황도 있었다. 저로서는 주차장을 통해서 건물들에 접근할 수 있습니다. 주차장은 여러 번 차들로 가득 차있어서 저는 그 곳을 지나갈 수가 없었습니다. [S5]
[Due to the] campus being so large, we have to cross several streets […] in order to change from class to class. There have been situations when the wheelchair was tipping over the sidewalk and I needed help to get up. […]. The access to the buildings for me is through the parking lot, [which] many times is full of cars and I just couldn't get through it. [S5]

[…] 캠퍼스를 돌아다니는 것은 우리를 지치게 하고 우리의 한계로 인해 우리를 피곤하게 만든다. [S8]
[…] moving around on campus wears us out and makes us tired due to our limitations. [S8]

청각 장애가 있는 학생들은 강의 중에 교수의 말을 듣는 것이 종종 어렵다.
For hearing impaired students, it is often difficult to hear the professor during the lectures:

선생님들이 수업시간에 사용하는 마이크는 소리가 크지 않습니다. 마이크 없이 말하는 것과 큰 차이가 없습니다. 듣지 않으면 배우기 어렵다. 의학에는 모르는 신조어가 많아서 가끔 이해가 안 될 때가 있어요. 나는 너무 창피해서 교수님께 […] 반복하라고 부탁할 수 없다. [S6]
The microphone [that teachers use during classes] is not very loud, it doesn't make much difference from talking without one. Not hearing makes it difficult for me to learn. In Medicine there are many new words that I don’t know, so sometimes I don't understand. I am too embarrassed to ask the professor to repeat […]. [S6]

이러한 불평등은 증폭 기술을 사용하여 해결할 수 있지만, 접근이 제한된다.
This inequality could be solved with the use of amplification technologies, however these are of restricted access:

저는 교수님의 근처에 놓을 수 있는 장치를 가지고 있고, 그것은 제 보청기와 바로 연결됩니다. 정부가 18세 이하의 사람들에게만 제공하기 때문에 [대학]은 내가 그것을 받을 것이라고 보장하지 않았다. [S6]
I have a device […] that I can place near the professor and it connects directly to my hearing aid. [The university] didn't guarantee that I would get it because the government only provides it for people under 18 years old […]. [S6]

주제 5: 실제 능력
Theme 5: Practical abilities

실제 의료기술을 익혀야 하는 실전학습 시나리오는 신체적인 노력이 필요하기 때문에 장애가 있는 학생들에게는 걱정스러운 상황이 될 수 있다. 많은 학생들이 이 활동을 수행할 수 없을까 두려워 마지막 단계에 도달했다고 보고했습니다.
The practical learning scenarios in which students need to learn practical medical skills can be worrisome situations for students with disabilities, because they demand physical effort. Many students reported that they put themselves at the last place in line, for fear of not being able to perform the activity:

[…] 수술 전에 손을 씻는 수업이었는데, 저는 벌써 맨 뒤로 가고 싶었습니다. [S1];
[…] It was a class on washing your hands before scrubbing into surgery, and I already [was] wanting to go to the back of the line. [S1];

우리는 삽관에 대한 강의를 하고 있었고, 그리고 나서 우리는 연습하기 위해 더미를 삽관해야 했습니다. 저는 모든 사람들 앞에서 활동을 하지 못하면 창피할 거라고 생각했습니다. [학생들]이 줄을 섰고, 다른 사람들이 먼저 하기를 기다렸기 때문에 마지막에 할 수 있었다. 나는 매우 초조하였다. [S2]
We were having a lecture on intubation, and then we had to intubate the dummy to practice. I thought, if I can't do [the activity] in front of everybody, I'll be embarrassed. [Students] formed a line, and I waited for everyone else to do it first, so I could do it at the end. I was nervous. [S2]

우리가 심장 마사지를 배울 때, 저는 제 손을 어떻게 위치시켜야 할지 몰랐습니다. 왜냐하면 저는 상지가 다른 다리보다 짧기 때문입니다. 나는 너무 창피해서 줄에서 꼴찌 두 번째로 자리를 잡았다. 내가 동료들 앞에서 그 일을 할 수 없게 되면 어쩌지? [S7]
When we were learning how to do cardiac massage, I didn't know how to position my hands, because I have an upper limb that is shorter than the other. I was feeling so embarrassed, […] I positioned myself to be second to last in line. What if I get in front of my colleagues and I can't do it? [S7]

이런 상황에서 학생들은 수업을 시작하기 전에 활동을 책임지는 선생님과 이야기를 나눌 수 있다면 불안감과 당황스러움을 덜 느낄 수 있을 것이라고 보고했다. 또한 피어 지원은 프로세스를 용이하게 합니다.
In these situations, students reported that they would feel less anxiety and embarrassment if they could talk to the teacher responsible for the activity before the class started. Peer support also facilitates the process:

저는 선생님께 제가 장애를 가지고 있다는 것을 설명할 수 없었고, 저를 도와줄 수 있는지 물어볼 수 없었습니다. […] [S7]
I couldn't reach the teacher and explain to him that I had a disability, ask if he could help me […] [S7]

저는 저와 친구만 있을 때까지 기다렸고, 제가 제대로 할 수 없다면 괜찮다고 생각했습니다. 왜냐하면 그녀는 제 친구이고 저를 판단하지 않을 것이기 때문입니다. [S2]
I waited until it was just me and a friend […] and I thought if I can’t do it properly, it's okay, because she is my friend and she won’t judge me. [S2]

내가 힘들었던 신체적인 면에서는 항상 친구들의 도움을 받았다. [S5]
[…] in the physical aspects where I had some difficulty, I always got some help from friends. [S5]

이동성 장애가 있는 PwD에게는 병원 및/또는 외래 진료소를 방문하는 것도 어려운 순간이다.
Visits to hospitals and/or outpatient clinics are also difficult moments for PwD with mobility impairment:

나는 대학 밖의 많은 진료소에 다녔는데, 이것은 접근성 문제를 가져온다. 여러 번 고백합니다. 제가 떠날 때 슬펐습니다. 왜냐하면 저는 포용하는 관점을 보지 못했기 때문입니다. [S5]
I have attended many clinics outside the University […] which brings the problem of accessibility. Many times I confess that I was saddened when I left, because I really didn't see a perspective of inclusion. [S5]

수술실에서, 저는 마취과 의사의 의자에 앉았습니다. […] 수술 분야를 잘 보지 못했기 때문에 좋지 않았습니다. […] 아마 내가 더 높은 의자를 구할 수 있다면, 나는 볼 수 있을 것이다.[S3]
In the surgical center, I sat in the anesthesiologist's chair. […] this was bad because I didn't have a good view of the surgical field. […] maybe if I could get a higher chair, I could see. [S3]

환자의 병상에서의 의료 방문과 병원 복도에서 교수들과의 사례 토론도 장벽을 가져올 수 있습니다.
The medical visit at the patient’s bedside and the case discussions with the professors in the corridors of the hospital can also bring barriers:

우리는 복도에서 모든 사람들이 일어선 가운데 어떤 사건을 토론하고 있었다. 그건 나한테 안 먹혀요. [S3]
We were discussing a case […] in the corridor, with everyone standing up. That doesn't work for me. [S3]

우리가 환자의 머리맡에 있을 때, 교수님이 설명을 하실 때, 그는 환자를 방해하지 않도록 낮은 목소리로 말해야 합니다. 또는 때때로 우리가 환자를 인터뷰할 때, 그들 중 몇몇은 매우 조용하게 말합니다. 저는 듣지 않게 되고, 사람들에게 계속 반복하라고 요구하지 않습니다.
When we’re at the patient’s bedside, when the professor is explaining, he has to speak in a lower voice so he doesn’t disturb the patient, or […] sometimes when we’re interviewing a patient, some of them speak very quietly […] I end up not listening, and I don't ask people to keep repeating themselves […] [S6]

해부학 실험실의 시체 해부는 상지에 차이가 있는 학생들을 위한 적응을 요구했다.
The dissection of cadavers in the anatomy laboratory demanded adaptations for students with differences in the upper limbs:

해부를 시작할 때 장갑의 문제가 있었는데, 오른손이 작고 손가락이 2개여서 일반 장갑이 잘 맞지 않기 때문입니다. […] 엄마와 나는 우리를 위한 맞춤형 장갑을 생산하는 공장을 찾았다. [S2]
When we started to practice dissection […] there was the issue of the glove, because my right hand is smaller and it has 2 fingers, so the normal glove does not fit well. […] my mother and I found a factory that produced custom gloves for us. [S2]

특히 신체 검사 시 학생이 환자와 접촉하는 과정에서 다른 어려움이 나타났다.
Other difficulties emerged in the student's contact with the patient, especially at the time of the physical examination:

저의 가장 큰 어려움은 환자와의 접촉입니다. [S6]
My biggest difficulty is […] the contact with the patient […] [S6]

신체 검사에서, 제가 할 수 없는 몇 가지 절차가 있을 것 같습니다. 제가 의사가 되면 환자를 완전히 진찰하고 제 한계에 최대한 적응할 수 있기를 바랍니다. [S7]
[…] in the physical examination, […] I think there are some procedures that I won't be able to do. When I become a doctor […] I hope I will be able to examine my patients in a complete way, adapt it as much as possible to my limitations. [S7]

논의
Discussion

장애를 가진 의대생들의 서사는 의료 및 학업 환경에서 이 인구의 삽입이 어떻게 발생하는지에 대한 풍부한 정보의 원천이다. 이 연구에서, 우리는 이러한 학생들을 완전히 포함하는 것에 대한 몇 가지 장벽을 발견했다:

• 학생들의 상태에 대한 교수진에 대한 사전 지식 부족,
• 적응 가능성에 대한 학생과 교사 간의 대화 부족,
• 장애에 대한 과소 평가,
• 커리큘럼에서 장애에 대한 접근의 부족(의학 교육의 유연하지 못한 것을 보여줌),
• 강의실과 강당에서 접근 가능한 구조의 부족

게다가, 학생들의 보고서는 [장애에 대한 사회적, 문화적 태도]를 포용의 강력한 결정 요소로 식별하기 때문에 장애인에 대한 생검 심리학적 관점을 확증한다.
The narratives of medical students with disabilities are a rich source of information about how the insertion of this population in the medical and academic environment occurs. In this study, we identified some barriers to the full inclusion of these students:

• lack of prior knowledge of the faculty about the students' conditions,
• lack of dialogue between students and teachers about possibilities of adaptation,
• underestimation of disability,
• lack of approach to disability in the curriculum (showing the inflexibility of medical education),
• lack of accessible structure in lecture halls and auditoriums.

Moreover, the students' reports corroborate the biopsychosocial view of the disabled individual, since they identify social and cultural attitudes towards disability as strong determinants of inclusion.

그런 의미에서 동급생들의 장애 수용 정도가 고등교육기관에 학생을 삽입하는 핵심 포인트로 파악된다. 장애를 자연스럽게 볼 때, 장애가 있는 사람은 사회적 맥락에 의해 그 또는 그녀의 존재가 입증되기 때문에 학생 신체에 더 쉽게 적응한다. 인터뷰한 학생들의 경험을 종합한 이 내용은 의학 교육에 대한 전문가들의 반영과 일치한다. 미국 의과대학협회(Meeks et al. 2018)의 조사에서는 동료 지원 네트워크의 존재가 PwD에 대한 접근 가능한 대학 개발에 가장 중요한 결정 요인 중 하나로 확인되었다.
In this sense, the degree of acceptance of disability by classmates is identified as a key point for the insertion of the student in the institution of higher education. When disability is seen naturally, the person with disability fits more easily into the student body, because his or her presence is validated by the social context. This synthesis of the experiences of the interviewed students is in agreement with the reflections of specialists in medical education. A survey by the American Association of Medical Colleges (Meeks et al. 2018) identified the presence of a peer support network as one of the most crucial determinants in the development of accessible universities for PwD.

의학계 전반을 바라보는 시각이 포용을 방해할 수 있다는 국제문헌은 더 나아가고 있다. 스테르지오풀로스 외 연구진(2018)은 의학에 의사를 완벽한 사람으로 보는 문화가 있다고 말한다. 이것은 어떤 학생도 약점을 드러내고 도움을 요청하는 것을 단념하게 하고, 따라서 장애가 있는 학생들은 그들의 특별한 필요를 증명하는 것을 두려워한다. 델리사와 토마스(2005)에 따르면, 이러한 완벽에 대한 기대는 PwD가 의료 행위를 할 수 있는 능력이 떨어지는 것으로 보이게 한다. 우리의 작업에서는 많은 학생들이 의대에 다닐 수 있는 능력이 있는지 스스로에게 물었고, 이러한 소속감 부족은 어떤 상황에서는 심각한 불편함을 드러냈다는 것을 관찰할 수 있다. 따라서, 일부 학생들은 교사들에게 도움을 요청하지 않았고 실기 활동에서 줄의 맨 뒤에 가서 또래들에게 그들의 장애를 숨기려고 했다.
The international literature goes even further, stating that the view of the medical community as a whole can hinder inclusion. Stergiopoulos et al. (2018) states that there is a culture in medicine that sees the doctor as a perfect person. This discourages any student from demonstrating weakness and asking for help, and thus students with disabilities are afraid to demonstrate their special needs. According to DeLisa and Thomas (2005), such expectation of perfection causes PwD to be seen as less capable of practicing medicine. In our work, it can be observed that many students asked themselves if they were capable of attending medical school, and this lack of sense of belonging manifested itself in a severe discomfort in some situations. Therefore, some students did not ask teachers for help and tried to hide their disability from peers by going to the back of the line in practical activities.

의료계에서 발생하는 포용 장벽 외에도 [사회 전반의 경제적 분열division]에서 발생하는 장벽을 고려하는 것이 중요하다. 더 [취약한 경제적 배경]에서 온 장애학생들은 [장애와 사회적 출신에 대한 이중적 배제]를 겪으며, 따라서 그들은 대학 진학 및 학업 진행에 있어 더 많은 어려움을 보고했다.
In addition to the barriers to inclusion that arise from the medical community, it is important to consider the barriers that arise from the economic division of society in general. Disabled students coming from more vulnerable economic backgrounds suffer a double exclusion, both for their disability and for their social origin, and therefore they reported more difficulty in entering University and in their academic progression.

이러한 모든 성찰은 이미 존재하는 포용법 이상의 것이 필요하다는 것을 지적합니다. 바로 [접근성에 전념하는 의료 커뮤니티의 건설]입니다. 이것은 장애가 있는 의대생들이 현재 수요가 높은 기술인 그들의 직업 전반에 걸쳐 공감 능력을 개발하는 데 도움을 줄 수 있는 개인적인 경험을 가지고 있다는 이해에서 출발할 수 있다. 울프 외. (2007)은 교사들은 [개인적인 질병 경험이 있는 학생들]을 더 성숙하고 동정심이 있다고 인식하였다고 말한다. 그러나, 이 연구는 [개인적 질병 경험이 있는 학생들]은 기대에 미치지 못할까봐 높은 수준의 불안감을 보였고, 이것은 우리의 연구에서 얻은 결과와 직접적으로 관련이 있다고 지적했다. 따라서, 장애가 있는 의대생들에 대한 이중 작업의 필요성은 의문으로 다가온다: 그들의 경험이 환자를 이해하는 데 얼마나 깊이 도움을 줄 수 있는지를 탐구하는 것, 그리고 또한 각 개인이 가지고 있는 한계에 대한 공동체의 존중을 위해 일하는 것.
All these reflections point to the need for something beyond the already existent inclusion laws: the construction of a medical community committed to accessibility. This can start from the understanding that medical students with disabilities have personal experiences that can help them develop empathy throughout their profession - a skill that is currently in high demand. Woolf et al. (2007) state that students with personal illness experiences were perceived by trained teachers as more mature and compassionate. However, the study pointed out that these students also showed high levels of anxiety associated with not meeting expectations, which speaks directly to the results obtained in our research. Thus, the need for dual work on disabled medical students comes into question: exploring how deeply their experiences can help them in understanding the patients, but also working on the community's respect for the limitations that each individual has.

장애학생과의 인터뷰 분석은 또한 다음과 같은 포용적 교육의 발전을 촉진할 수 있는 구체적인 개입 가능성을 제기한다.

• 대학 행정부가 접근 가능한 공간(램프, 엘리베이터)과 특수 기술(교수용 마이크 및 앰프, 시각 장애 학생을 위한 디지털 테스트)에 투자하도록 장려하는 장애인 학생 단체가 주도하는 대표자 기관 설립
  
• 의과대학에 재학하는 동안 어떤 [특별한 요구]가 발생할 수 있는지 판단하기 위해, 포용적 교육을 받은 교사 그룹에 의한 각 의과대학 신입생에 대한 평가
  
• 각 기관의 웹사이트에서 쉽게 이용할 수 있는 접근성에 대한 정보를 제공하여 미래의 장애학생들에게 숙소 마련의 가능성을 알려준다.
  
• 이 인구집단의 요구에 대한 의료계의 지식을 높이기 위해 장애 의대생과 함께 더 많은 설문조사를 실시한다.
  
• 모든 의대생(유형 및 기타)이 또래와 환자의 장애에 대해 배울 수 있는 커리큘럼을 수립하여 이 주제에 대한 인식을 높이고 장애 환자에 대한 치료의 질을 높인다.

이러한 이니셔티브를 통해, 법의 이론을 넘어 실제로 나타나는 포함을 향한 길을 시작할 수 있을 것입니다.

The analysis of the interviews with the students with disabilities also raises concrete possibilities for intervention that can advance the development of inclusive education, such as:

• establishing representative institutions led by disabled student groups that would encourage the University administration to invest in accessible spaces (ramps, elevators) and special technologies (microphones and amplifiers for professors, digitized tests for visually impaired students);
• assessment of each medical freshman by a group of teachers instructed in inclusive education to determine what special needs may arise throughout their time in Medical school;
• easily available information on accessibility on each institution's website to inform future disabled students on the possibility of making accommodations;
• conducting more surveys with disabled medical students to increase the medical community's knowledge regarding the needs of this population;
• establishing a curriculum for all medical students (abled bodied and otherwise) to learn about disabilities in their peers and patients, therefore raising awareness on this topic and increasing the quality of care for disabled patients.

With initiatives like these, it will be possible to start the path towards an inclusion that goes beyond the theory of the law and manifests itself in practice.

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Med Teach. 2022 Mar;44(3):294-299. doi: 10.1080/0142159X.2021.1985098. Epub 2021 Oct 7.

Experiences of disabled students in undergraduate medical education

Elda de Oliveira 1, Rafaela Gonçalves Dantas 2, Giovanna Araujo Amaral 2, Renata Rocha Barreto Giaxa 3, Aécio Flávio Teixeira de Góis 4

Affiliations collapse

Affiliations

1Universidade de São Paulo (USP), Escola Paulista de Enfermagem, Universidade Federal de São Paulo (EPE/UNIFESP), São Paulo, Brazil.

2Escola Paulista de Medicina (EPM/UNIFESP), São Paulo, Brazil.

3Center of Development of Medical Education (CEDEM) of Universidade de São Paulo, São Paulo, Brazil.

4Faculdade de Medicina da Universidade de São Paulo (FMUSP), Healthcare Management in Fundação Getúlio Vargas (FGV), Escola Paulista de Medicina (EPM), São Paulo, Brazil.

PMID: 34618650

DOI: 10.1080/0142159X.2021.1985098

Abstract

Purpose: Since people with disabilities (PwD) are underrepresented in medical education, the authors of this article conducted a qualitative research in the form of an in-depth interview with students with disabilities from a medical school in Brazil, to characterize their experiences in medical education and identify barriers and facilitators to inclusion.

Materials and methods: Participants were recruited by snowball sampling, signed an informed consent form, and completed a socioeconomic questionnaire. They were interviewed individually with open-ended questions so that they could develop narratives.

Results: The students identified some barriers to inclusion - teachers' lack of knowledge about students' special needs, students' own lack of knowledge about their needs during the medical course, underestimation of the disability by teachers and classmates, difficult access to college buildings - and facilitators, such as acceptance of the disability by professors and colleagues, proactivity of professors and colleagues in adapting practical learning scenarios.

Conclusion: Students identified peer and teacher acceptance as an important determinant of inclusion, which is in line with the biopsychosocial view of disability. They also reported doubts about their ability to practice medicine, which dialogues with literature research that points to a medical culture that expects nothing less than perfection from students.

Keywords: Undergraduate medical education; disabled persons; inclusive education; qualitative research.