악마는 본과3학년에 있다 - 무엇이 학생들의 공감능력을 갉아먹는가?

악마는 본과3학년에 있다 - 무엇이 학생들의 공감능력을 갉아먹는가?

The Devil is in the Third Year: A Longitudinal Study of Erosion of Empathy in Medical School

Mohammadreza Hojat, PhD, Michael J. Vergare, MD, Kaye Maxwell,

George Brainard, PhD, Steven K. Herrine, MD, Gerald A. Isenberg, MD,

Jon Veloski, MS, and Joseph S. Gonnella, MD

Abstract

Purpose

This longitudinal study was designed to examine changes in medical students’ empathy during medical school and to determine when the most significant changes occur.

Method

Four hundred fifty-six students who entered Jefferson Medical College in 2002 (n 227) and 2004 (n 229) completed the Jefferson Scale of Physician Empathy at five different times: at entry into medical school on orientation day and subsequently at the end of each academic year. Statistical analyses were performed for the entire cohort, as well as for the “matched” cohort (participants who identified themselves at all five test administrations) and the “unmatched” cohort

(participants who did not identify themselves in all five test administrations).

Results

Statistical analyses showed that empathy scores did not change significantly during the first two years of medical school. However, a significant decline in empathy scores was observed at the end of the third year which persisted until graduation. Findings were similar for the matched cohort (n 121) and for the rest of the sample (unmatched cohort,

n 335). Patterns of decline in empathy scores were similar for men and women and across specialties.

Conclusions

It is concluded that a significant decline in empathy occurs during the third year of medical school. It is ironic that the erosion of empathy occurs during a time when the curriculum is shifting toward patient-care activities; this is when empathy is most essential. Implications for retaining and enhancing empathy are discussed.

Acad Med. 2009; 84:1182–1191.

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의학은 본질적으로 서비스업이다. 그래서 다음의 것들이 중요하다.

Medicine at its core is a human service profession. Cultivating humanistic values in general and enhancing interpersonal skills and empathy in particular are of paramount importance in any human service endeavor. 

AAMC의 MSOP에서도 그러한 것들을 강조하고 있다. 미국 내과 협회에서는 성명서를 통해서 humanistic value와 empathy가 졸업후교육의 핵심적 교육활동이 되어야 한다고 제언했다.

Consistent with this notion, the Medical School Objectives Project of the Association of American Medical Colleges1 includes enrichment of interpersonal skills and empathy among the educational objectives of undergraduate medical education. In a position paper, the American Board of Internal Medicine2 recommended that humanistic values and empathy should be cultivated and assessed as an essential educational activity in graduate medical education.

이렇게 각 단체와 리더들이 중요성을 강조하고 있음에도 empathy(공감)에 대한 연구는 부족하다.

Despite the consensus of professional organizations and medical education leaders on the importance of empathy in medical education and the practice of medicine, empirical research on empathy, including its development, and erosion is scarce. 

수련중에 있는 의사에게 공감능력을 강화하는 것에도 관심이 부족하다. 이는 공감능력이라는 것에 대한 개념적 혼란뿐만 아니라 의학교육과 환자돌봄에 대한 공감을 측정할 만한 타당한 도구가 없는 것도 그 이유이다. 이러한 도구가 없는 한, 어떤 요인이 공감능력을 향상시키는지, 감퇴시키는지 알아내는 연구도 쉽지 않다.

Consequently, sufficient attention has not been directed toward the enhancement of empathic skills for

physicians-in-training. Empirical research on empathy among medical students and physicians has been hampered not only by a conceptual confusion but also by the lack of a sound instrument to measure empathy specifically in the context of medical education and patient care. Without a valid measurement of empathy that is content-specific to patient care, it is not feasible to determine what factors lead to its enhancement or degradation among physicians-in-training.

공감이란 무엇인가?

What Is Empathy?

공감이라는 것의 개념은 모호하다. 정의에 대한 컨센서스가 없기 때문에 문헌에서 이를 묘사하는 것도 다양하다. 또한 개념이 모호해서 정의하거나 측정하는 것도 쉽지 않다. 일반적으로 공감을 '인지적 특질'이라고 분류하는 연구자들도 있다. 왜냐하면 공감이라는 것이 상당부분 다른 사람이 무엇을 걱정하고 있는가를 다루기 때문이다. 또 다른 연구자들은 정서적/정동적 특질이라고 하기도 하는데, 이는 다른 사람의 통증과 고통에 공감하는 의미에서 그러하다. 정동적인 특질이면서 인지적 특질이라고 보는 시야도 있다.

Empathy is an ambiguous concept. Despite a lack of consensus about its definition, there are various descriptions or characterizations of the term in the literature.3(pp 3–15) Because of this conceptual ambiguity, empathy has been described as a notion that is difficult to define and hard to measure.4 

Generally, some researchers have described empathy as a cognitive attribute,5,6 which means it predominantly involves understanding another person’s concerns. 

Others have described empathy as an affective or emotional characteristic,7,8 which implies that it primarily involves feeling another person’s pain and suffering. 

Yet, there is a third group that views empathy as both affective and cognitive.9,10 

공감을 명확하게 개념화하는 것은, 그 개념화라는 것이 조작적 정의(operational definition) 측면에서 중요하고, 공감을 측정하는 내용-특이적 도구를 개발하는데 있어서도 중요하다. 또한 '공감'을 향상시키기 위한 전략을 수립하는 것에 있어서도 중요하다.

A clear conceptualization of empathy is critically important because conceptualization not only can serve as a guideline for an operational definition of the term but also can provide a framework for the development of a content-specific instrument for measuring empathy in the context of medical education and patient care. Also, strategies to enhance empathy can be more appropriately developed on the basis of a clear definition of the concept.

개념을 명확히 하기 위하여 공감을 정의했다.

To clarify the conceptual ambiguity associated with empathy, based on an extensive review of relevant literature,3,11 we defined empathy in the context of medical education and patient care as...

• a predominantly cognitive (as opposed to affective or emotional) attribute that involves an understanding (as opposed to feeling) of patients’ experiences, concerns, and perspectives combined with a capacity to communicate this understanding. 
• An intention to help by preventing and alleviating pain and suffering is an additional feature of empathy in the context of patient care.

이 정의의 핵심 언어는 다음과 같은 이유로 선정되었다.

The key terms in this definition are italicized for two reasons: 

(1) to underscore their importance in the construct of empathy in the context of medical education and patient care, and 

(2) to make a distinction between empathy and sympathy, which have often been used interchangeably.

공감 vs 동정

Empathy versus sympathy

동정심은, 곰감과 달리 정동적/정서적 특질로서 환자의 고통과 통증에 대한 강력한 감정이다. 정의는 서로 다르지만 완전히 독립적인 개념으 아니다. 한 연구에 따르면 correlation이 0.49정도로 둘 사이에 25%정도 중첩된다고 할 수 있다.

Sympathy, as opposed to empathy, is predominantly an affective or emotional attribute that involves intense feelings of a patient’s pain and suffering. Despite the differences in conceptualization, the two notions are not entirely independent. One study reported a moderate correlation of 0.49 between measures of the two concepts, which can be translated into approximately a 25% overlap between the two.12

두 개념을 섞어 쓰는 것은 사회심리학에서는 별 문제가 아닐 수 있지만, 환자진료에 있어서는 다르다. 둘 사이의 동기가 다르더라도 사회심리학에서는 두 가지 모두 '친사회적' 결과를 가져올 수 있다. 그러나 동정심에서 기인한 사회적 행동은 자신의 스트레스를 줄이기 위한 이기적인 행동에 의해서 나온 것이다.

The interchangeable use of these two concepts may not cause a problem in the context of social psychology, but it is important to separate the two in the context of patient care. In social psychology, both empathy and sympathy can lead to a similar outcome (e.g., prosocial behavior), albeit for different behavioral motivations. For example, a prosocial behavior that is induced by empathic understanding is more likely to be elicited by a sense of altruism. A prosocial behavior that is prompted by sympathetic feelings, however, is more likely to be triggered by egoistic motivation to reduce personal distress.3

의학교육과 환자진료의 맥락에서는 둘 사이의 구분을 해야 하는데, 왜냐하면 서로 다른 행동과 환자결과(patient outcome)을 가져올 수 있기 때문이다. 공감은 경험의 '질'에 대해 걱정하고, 동정은 경험의 '양'에 대해 걱정한다.

관심을 가지게 되는 영역의 차이

In the context of medical education and patient care, however, we must make a distinction between the two constructs because, in this context, they lead to different clinical behavior and patient outcomes.13    

An empathic physician would be more concerned about understanding of the kind and quality of patients’ experiences, whereas 

a sympathetic physician would be more concerned about feeling the degree and intensity (quantity) of patients’ experiences.3 

공감의 인지적 측면으로 인해서 공감이 과한 것은 환자-의사 관계에서 언제나 이득이 되지만, 동정의 정동적 측면으로 인해서 동정이 과한 것은 환자-의사 관계에 해로울 수 있고 의사의 수행능력에도 부정적일 수 있다.

과도했을 때 나타나는 결과의 차이

Because of its cognitive nature, empathy in excess is always beneficial in patient–physician relationships. In contrast, because of its affective nature, an overabundance of sympathy can be detrimental in patient–physician relationships and can impede the neutrality that is necessary in clinical decision making, thus negatively influencing a physician’s performance.

공감이 높으면 개인이 성장하고 직무에 대한 만족이 높아지나, 동정이 높으면 burnout되고 피로해진다.

개인에게 나타나는 영향의 차이

Cognitively defined empathy always leads to personal growth, career satisfaction, and optimal clinical outcomes, whereas affectively defined sympathy can lead to career burnout, compassion fatigue, exhaustion, and vicarious traumatization.14

공감과 임상결과는 선형적 상관관계가 있으나, 동정과 임상결과는 뒤집어진 U모양의 관계를 가진다. 즉 과도한 동정은 오히려 악이다.

임상결과와의 상관관계

Indeed, it can be assumed that the relationship between empathy and positive outcomes is linear, meaning that the outcomes progressively become better as a function of an increase in empathy. In contrast, it can be assumed that the relationship between sympathy and clinical outcomes is like an inverted U shape (similar to that between anxiety and performance), meaning that sympathy to a limited extent can be beneficial, but excessive sympathy can be detrimental.

또 다른 중요한 차이점은 정동/정서는 변하기 쉽지만 인지/이해는 교육에 의해 강화될 수 있다. 즉 공감은 가르칠 수 있지만, 동정은 교육을 통해 잘 변하지 않는다. 공감과 동정의 차이가 table1에 정리되어 있다.

교육에 의한 강화/변화 가능성

Another important implication for making a distinction between empathy and sympathy in medical education is the fact that affect and emotion (the prominent ingredients of sympathy) are less amenable to change, whereas cognition and understanding (the prominent ingredients of empathy) can be substantially enhanced by education. This implies that empathy can be taught, but sympathy is not easily amenable to change through education. Specific features of empathy and sympathy are summarized in Table 1. More detailed descriptions of those features are given elsewhere.3(pp 7–15,79–85)

측정

Measurement

지금까지의 지식으로는 JSPE가 개발되기 이전에는 측정가능한 방법이 없었다. 일반 인구집단을 대상으로 한 것은 있지만 의학교육에서 또는 환자진료에 관한 것은 없었다.
To the best of our knowledge, before the development of the Jefferson Scale of Physician Empathy (JSPE), no psychometrically sound research instrument was available to measure empathy specifically among medical students, residents, and physicians. A few research tools exist for measuring empathy in the general population,3(pp 63–74) but none is content-specific to medical education and relevant to patient care. 

공감이란 것이 특정 환경에서만 나타나는 것은 아니지만 세 가지 도구가 주로 사용되어 왔다.

Although they are not content-specific, three empathy-measurement instruments have been frequently used in medical education research. 

(1) The Interpersonal Reactivity Index (IRI) was developed by Davis9 and includes 28 items tapping both cognitive and emotional empathy. The IRI contains four scales: 

perspective taking, 

empathic concern, 

fantasy, and 

personal distress. 

A typical item (from the perspective taking scale) is, “I sometimes try to understand my friends better by imagining how things look from their perspective.”

(2) Another research tool is the Empathy Scale developed by Hogan15 which includes 64 items. 

A typical item is, “I have seen some things so sad that I almost felt like crying.” 

(3) The third research tool is the Emotional Empathy scale developed by Mehrabian and Epstein16 which includes 33 items intended to measure “emotional empathy.” A typical item is, “It makes me sad to see a lonely stranger in a group.”  

(3') Mehrabian introduced a new 30-item instrument, the Balanced Emotional Empathy Scale (BEES),17 to measure vicarious emotional empathy. A sample item is, “Unhappy movie endings haunt me for hours afterward.” 

앞에서 기술한 바와 같이, 이 도구들 중 어떤 것도 의학교육/환자진료에 대해서만 특이적이지는 않다. BEES외에 나머지 셋애 대해서는 연구된 바가 많다.

As indicated before, and reflected in the sample items, none of the aforementioned instruments feature content specific to medical education and patient care. With the exception of the BEES, extensive psychometric data have been published for the other three instruments.3(pp 66 – 69,72–73)

JSPE

The JSPE

몇 년 전, JMC의 한 연구진은 공감을 측정할 도구의 필요성을 느꼈다.

Several years ago, a group of medical education researchers at Jefferson Medical College recognized a need for an instrument to measure empathy in the context of medical education and patient care. In response to this need, and on the basis of the above-mentioned, cognitively defined empathy and a comprehensive review of the literature, they developed the JSPE. 

JSPE의 단계별 개발과정과 타당성, 신뢰성은 다른 문헌에 있다. 20개 문항이며 7점 만점의 Likert scale로 되어있다.

Step-by-step procedures in the development of the JSPE and data in support of its validity and reliability are reported elsewhere.3(pp 87–115) The scale is brief and includes 20 items answered on a seven-point Likert-type scale (Strongly Agree 7, Strongly Disagree 1). 

"맹목적(acquiescence)"응답을 통제하기 위해서 10개 아이템은 긍정형, 10개 아이템은 부정형으로 되어 있다. 25개 언어로 번역되어있다.

To control for the “acquiescence” response style (a tendency to passively and consistently endorse “agree” [or “disagree”] responses to the test questions), 10 items are positively worded (directly scored) and 10 items are negatively worded (reverse scored). The JSPE has received broad attention and has been translated into 25 languages to date.

여러 버전의 JSPE가 있다.

Different versions of the JSPE are available: 

one for administration to medical students (S-Version), 

one for administration to physicians and other health professionals (HP-Version), and 

one for administration to students in any health profession fields other than medicine. 

이들은 내용은 비슷하고, 말만 조금 바꾼 것이다. 

These versions are similar in content with slight changes in wording to reflect students’ orientation toward empathy in medical education (S-Version), or in other health profession education (HP-Version for Students), and behavioral tendencies toward empathic engagement in patient care (HP-Version for physicians and other health professionals). 

예를 들면 이렇다.

For example, an item in the medical students’ version that reads, 

“Patients feel better when their physicians understand their feelings,” reads as 

“Patients feel better when their health care providers understand their feelings” in the version for nonmedical health professional students and reads as 

“My patients feel better when I understand their feelings” in the HP-Version for physicians.

JSPE의 구인타당도, 준거연관타당도, 예측타당도, 내적신뢰도, 검사-재검사 신뢰도 등이 보고된 바 있다.

Evidence in support of the JSPE’s construct validity,3,11,12 criterion-related validity,12,18 predictive validity,19 internal consistency reliability,11,12 and test-retest reliability11 has been reported. 

요인분석에서는 세 가지 요인이 나타났다.

Factor analysis of the JSPE in medical students3 and physicians11 resulted in three factors. 

The grand factor (prominent component) of the scale involves a construct entitled “perspective taking,” which is considered an important ingredient of empathy. 

A related sample item from the S-version is, “Physicians’ understanding of the emotional status of their patients, as well as that of their families, is one important component of the physician–patient relationship.” 

The second component of the JSPE, “compassionate care,” is considered an essential dimension of the patient–physician relationship. 

A related sample from the S-version item is, “Attention to patients’ emotions is not important in history taking.” This is a negatively worded item which is reverse scored. 

The third component is the “ability to stand in patients’ shoes,” which was a trivial factor because only two items had significant factor coefficients on this factor. 

A related sample item is, “Because people are different, it is difficult to see things from patients’ perspectives” (a reverse scored item). 

다른 연구에서도 비슷한 결과가 나타났다 (치대, 간호대 // 멕시코, 일본, 한국, 이탈리아 등)

A similar underlying construct of JSPE has emerged among students in dental school,20 nursing students,21 Mexican medical students,22 Japanese23 and Korean24 medical students, and Italian physicians.25

공감의 변화

Changes in empathy

일부 보고된 일화들이라든가 경험적 연구들은 의과대학생들이 의학교육중간에 엄청난 변화를 겪는다고 말하고 있다. 맨 처음 의사가 되기 위한 과정을 시작했을 때는 열정적이고, 이상적이고, 다른 사람을 돕겠다는 진심을 가지고 있지만, 아이러니하게도 학생들의 인간적 측면을 키워주고자하는 의과대학의 노력에도 불구하고 이러한 초창기의 좋은 의지들은 배우는 도중에 냉소주의로 바뀐다.

Some anecdotal reports as well as empirical studies suggest that a drastic transformation in medical students’ character occurs during their medical education. When they embark on the journey to become physicians, most students are enthusiastic, filled with idealism and a genuine intention to serve those in need of help.26,27 It is ironic, though, that despite the students’ initial intentions and medical school faculty’s attempts to nurture human qualities, a cynicism develops progressively during their training.26–29 

For example, it has been reported that as many as three fourths of medical students become increasingly cynical about academic life and the medical profession as they progress through medical school.28 It has also been found that 61% of medical residents reported becoming cynical during their postgraduate training.30 

이렇게 시니컬해지는 것은 battered child syndrome피학대아 증후군과 비슷하다. 비슷한 묘사로 “traumatic de-idealization”26 and “dehumanization.”31 가 있고, '재인간화'가 필요성이 주장되고 있다.

This cynical transformation was likened to the “battered child syndrome” and attributed to inappropriate treatment of medical students.27 The metamorphosis has been described as “traumatic de-idealization”26 and “dehumanization.”31 It has been suggested that a “rehumanization” process is needed to retain and enhanceempathy among physicians-intraining.32

몇몇 연구에서 공감능력 역시 점차 감소한다는 것을 보여주고 있다. 

Several empirical studies have shown a decline in empathy during undergraduate and graduate medical education. 

In a cross-sectional study, Chen and colleagues33 reported a noticeable decline in empathy scores (measured by the JSPE) in third-year medical students as compared with their second-year counterparts.
In another cross-sectional study with dental school students, Sherman and Cramer20 noticed a significant decline in empathy (measured by the JSPE) in second-year students. 

공감의 저하에 관한 두 개의 longitudinal study도 보고된 바 있다.

Two longitudinal studies have recently been published on the decline of empathy in medical school. 

Newton and colleagues34 reported a drop in vicarious/ emotional empathy (measured by the BEES)17 during medical school. 

In another longitudinal study of medical students, a significant decline was observed in scores of the JSPE, which was administered at the beginning and the end of the third medical school year.35 

레지던트 수련기간의 공감 저하도 지적되고 있다.

Research also indicates that empathy continues to decline during residency training. 

Bellini and Shea36 used the IRI9 with internal medicine residents and reported a significant drop in scores of the “Empathic Concern” scale of the IRI, but an increase in scores of the “Personal Distress” scale of the IRI, which is an indicator of emotional empathy in the general population. 

Mangione and colleagues37 noticed a downward trend in empathy scores (measured by the JSPE) as residents progressed through different years of internal medicine residency training, but the differences did not reach the conventional level of statistical significance (P .05).

이들 연구가 의학교육과정에서 일어나는 공감 저하에 대한 문제를 지속적으로 제기하고 있지만, 이게 정확히 왜, 언제 일어나는지 아는 것이 중요하다. 그래야 적절한 개입이 가능하기 때문이다.

Although these studies generally suggest that an erosion of empathy occurs during medical education, it is important to discern exactly when and why the erosion of empathy occurs. This issue is of interest to medical educators because of its implications for timely educational intervention.

두 가지를 중요하게 고려하려고 한다.

We should keep in mind that two features are important in providing an appropriate answer to the aforementioned issue. 

First, we need a longitudinal (as opposed to across-sectional) research design to follow the same group of students in different stages of medical education to examine changes in each stage. 

Second, we need to use a psychometrically sound measure of cognitive empathy (not affective, reactive, vicarious, or emotional empathy, which are analogous to sympathy)3 that is both content-specific and context-relevant to medical education and patient care. 

본 연구의 목적은 이러한 공감의 변화가 포괄적이고, 진행적인지, 아니면 연속성이 없는 분절된 사건인지 알고자 한다. 즉 '가장 큰 변화가 일어나는 시기는 언제인가?'하는 것이다.

The purpose of this study was to ascertain whether changes in empathy during medical school are systematic and progressive or disjointed without continuity. In particular, we addressed the following question: When do the most significant changes in empathy occur during medical school?

방법

Method

참여자

Participants

JMC의 456명의 학생들

Our total study cohort included the 456 students who entered Jefferson Medical College in 2002 and 2004. 

This represents 100% of matriculants in these two classes. 

Of the total participants, 50% (n 226) were women, and 74% (n 338) were white, 21% (n 95) were Asian American, 3% were Latino (n 12), and 2% (n 11) were black. Instruments 

JSPE사용.

We used the JSPE (S-Version) in this study. 

추가로 다음의 질문

In addition, to examine the reasons for any changes in empathy, we asked participants to respond to the following open-ended statement at the end of each academic year at the time the JSPE was administered: 

“Please describe briefly events or experiences (e.g., personal, academic, role model, etc.) in the past year that have influenced (either positively or negatively) your views on the humanistic aspect of medicine (e.g., empathy toward patient, patient–physician relationship, etc.).”

절차

Procedures

IRB승인.

This study, as part of the Jefferson Longitudinal Study of Medical Education (http://jdc.jefferson.edu/jlsme), approved by the IRB of Thomas Jefferson University, was conducted during a six-year period between August 2002 and March 2008. In August 2002, the JSPE was administered to 227 students during the orientation program at the beginning of their first year of medical school and then readministered in 2003 at the end of their first academic year. Subsequently, the JSPE was readministered to this cohort three more times in medical school near the end of their second, third, and fourth years in 2004 through 2006. 

2003년, 2004년..

In August 2003, a similar procedure was started for first-year students, but data collection on that cohort was suspended because of difficulties in scheduling all the test readministrations. Once again, in August 2004, the JSPE was administered to 229 first-year students at orientation and readministered four more times at the end of the each year through graduation in 2008.

참여는 자발적으로 이루어졌고, 이름과 학번 등은 선택적으로 기입하도록 했음. 따라서 모든 학생이 자신의 신분을 밝힌 것은 아니며, 'matched cohort'가 있고, 'unmatched cohort'가 있다.

Participation was voluntary, and supplying personal identification information such as names or student identification numbers was optional. Therefore, not all of the students identified themselves in all test administrations. Because of this, longitudinal data were analyzed for two groups of cohorts: The “matched cohort” was the 121 students who identified themselves in all of the five test administrations, and the “unmatched cohort” (total n 335) was those who did not identify themselves in one or more of the five test administrations. 

통계 분석

Statistical analyses

두 코호트에서 분석을 분리해서 했음.

We performed statistical analyses separately for the total study cohort, and for the matched and unmatched cohorts. 

We calculated descriptive statistics for comparisons of changes in empathy scores during medical school for both cohorts. 

In addition to descriptive statistics, we used inferential analyses (analysis of variance for repeated-measure design) to detect the statistical significance of changes in empathy scores in the matched cohort. 

We also used the t test to test the significance of the differences in pairwise comparisons. 

Also, when appropriate, we calculated the effect size estimates (e.g., Cohen d) to examine whether statistically significant differences in empathy scores were also practically (clinically) significant.38

결과

Results

Findings are presented separately for the total study sample and the matched and unmatched cohorts.

Total participants

Comparisons of the matched and unmatched cohorts

Gender differences

Differences across specialties

고찰

Discussion

본 연구의 결과는 의과대학3학년에서 공감에 대한 상당한 저하가 일어났다는 것을 보여준다. 남-여 간에 비슷했고, people-oriented 든, technology-oriented 든 마찬가지였다. 여학생의 점수가 더 높았으며 people-oriented에서 더 높았다.

The results of this study showed a significant decline in mean empathy scores in the third year of medical school. The patterns of decline were similar for men and women and for those who pursued their medical training in people-oriented and technology-oriented specialties. Consistent with previous findings, our results showed that women obtained a higher mean empathy score than men,11,12,40 and those in the people-oriented specialties outscored their counterparts in technology-oriented specialties.11,40

중요한 것은, 저하의 정도가 남자에서 더 컸고, technology-oriented career를 추구하는 집단에서 더 컸다는 점이다.

It is interesting to note, however, that the magnitude of the decline, measured by the effect size estimates, was larger for men compared with women, and for those who pursued technology-oriented careers compared with their counterparts in people-oriented specialties. 

The aforementioned findings suggest that those with lower empathy scores at the beginning of medical school (e.g., men and students interested in technology-oriented specialties) lost more empathy during medical school than others with relatively higher empathy scores at the baseline. 

의대 시작시점에서 낮은 점수였던 사람이 더 많이 떨어진다는 뜻이며, '위험군'이 있다는 뜻이기도 하다

This pattern of finding suggests that there are “at-risk” medical students who are more vulnerable to losing their sense of empathy. 

3학년에서 무슨 일이 일어난 것일까?

What happens in the third year of medical school that hardens “the human heart by which we live”41(p 5) and generates a noise that obscures the signal of empathic connection? The erosion of empathy in medical school can be attributed to several factors, 

including lack of role models, 

a high volume of materials to learn, 

time pressure, and patient and environmental factors. 

또한 컴퓨터 기반 진단과 치료기술들이 오히려 환자와의 인간적 접촉에 대한 중요성을 제한했을 수도 있다. 시장중심의 보건의료시스템이 공감에 대한 잘못된 인식을 심어준 것이다.

In addition, students’ gradual overreliance on computer-based diagnostic and therapeutic technology limits their vision for the importance of human interactions in patient encounters. Changes in the market-driven health care system that have a ripple effect on medical education, combined with the belief that a controlled clinical trial is the royal road to advances in medicine, can also lead to a false idea that empathy is outside the realm of evidence-based medicine and, thus, has no importance in the education of physicians-in-training or in the practice of medicine.

또한 현대의 의학교육은 의학의 과학적 측면을 강조하고 환자진료의 'art'를 방치하면서 점차 의사가 정서적으로 환자와 분리되도록 유도하고, 정서적 거리를 두도록 만든다. 학생들은 환자진료 과정에서 인간적인 관계를 피해야 하는 것이라고 잘못 해석할 수 있다.

In addition, modern medical education promotes physicians’ emotional detachment, affective distance, and clinical neutrality42–44 as emphasized through a focus on the science of medicine and a benign neglect of the art of patient care. Students can easily misinterpret these lessons as an endorsement of avoiding interpersonal engagement in patient care. Thus, this educational approach contributes to an erosion of empathy among medical students, residents, and practicing physicians. 

그 외에도...

Lack of role models,45,46 

an intimidating educational environment, 

negative educational experiences,47,48 

partial sleep deprivation,49 and 

perception of “belittlement and harassment” in medical school50 

have also been described as factors contributing to the atrophy of compassion among physicians-in-training.

이런 요인들이 상당한 영향을 줬지만 일부 학생에서는 그럼에도 공감이 감소하지 않았고, 이는 어떤 보호 요인이 있음을 의미한다.

Although these unfavorable factors can influence a great majority of medical students, our findings that empathy did not decline for some students (a minority of 27%) suggest that there may be certain protective factors that defuse the harmful influences. Further research is needed to investigate the protective factors that neutralize the erosion of empathy. 

주관식 문항을 분석하였을 때 환자-의사 관계에 대한 서로 다른 관점이 드러난다. 몇 가지 반복되는 주제들이 있었다.

When analyzing the content of students’ responses to the open-ended question asking about experiences that altered their views on the patient–physician relationship, we found several common themes. Students noted that the behavior of their superiors affected their own experiences: 

“At an affiliated hospital… a particular attending is notorious for vulgar humor and unprofessional attitudes. So many times he made my jaw drop by the comments,” and 

“resident and attending negative attitudes set the style in which we will act.” 

Another student reflected that “we are always being reminded to keep a professional distance, but some doctors take it too far.” 

이러한 코멘트들은 적절한 롤모델이 없는 것이 주는 영향을 알 수 있지만, 모든 학생이 여기에 영향을 받는 것은 아니다.

Such comments reflect the negative impact of inappropriate role models. The effect of inappropriate role models, however, is not negative for all students. 

For example, a student wrote, “I learn [what to do] from ‘good’ docs and I learn what not to do from ‘bad’ ones!” 

또한 환자진료시에 마주하는 '현실'이 일부 학생의 열정을 앗아가기도 한다.

In addition, patient-care realities, such as overly demanding patients, lack of appreciation, malpractice issues, restrictions on caregivers’ autonomy imposed by hospital guidelines, and insurance regulation, contribute to fading enthusiasm in some, but not all, medical students. 

For example, one student recalled “a patient who was very difficult …was very bitter and verbally abusive to the hospital staff.” 

Further, “It is difficult to have empathy for people who don’t take care of themselves.” 

One participant recalled “a trauma patient who gladly told us he’s living off compensation money he was granted in a medical malpractice case.” 

As another student stated, “I’m convinced it’s easier to be a doctor in rural third world countries, without all the malpractice, insurance, and reimbursement worries of the USA.” 

주치의들이 '의학은 사업이야'라고 반복적으로 말하는 환경에서 공감을 유지하기란 쉽지 않다.

It is difficult to maintain an empathetic patient–physician relationship when “attendings have repeatedly said medicine is business.” 

실수에 대한 두려움, 과중한 교육과정 등등도 환자-의사 관계에 대한 생각을 바꾸게 하는 요인이다.

Fear of making mistakes, a demanding curriculum, time pressure, sleep loss, and a hostile environment have all been described by some students as factors that changed their views about patient–physician relationships. 

As one student wrote, “I have felt overwhelmingly tired and unempathetic at times—It is the feeling where, upon walking into a patient’s room, I am thinking more about getting through the encounter expeditiously than about making a connection with the patient. AND, I have always considered myself an empathetic person.” 

One student illustrated the point facetiously: “I am too sleepy to render a sufficient answer” while another revealed that “it is hard to care 100% about some patients’ stories when you are tired and have a ton of people to see.” Simply put, “I think having too little time and being too busy destroys empathy.” Further, “It is difficult to walk in every patient’s shoes when you see so many patients in such a short time frame.” 

수련과정과 환경에서 오는 스트레스 역시 학생들에게 큰 부담이다.

Stressful training and practice environments place heavy, unrealistic demands on many students. “I think that physicians today are under so much external pressure—liability, insurance, etc.—that the patient becomes secondary.” Reflecting on the nature of the training environment, one student stated, “I was constantly reminded of the hierarchy of medicine and how it was not the student’s job to speak up even if in defense of patients’ best interest. The bureaucratic side of medicine overshadowed the human, empathic side.” When students perceive from their training experiences that the “humanistic side of medicine is too soft and a waste of time . . . . I worry that over time I will be ‘molded by the system’ into this idea.” 

일본이나 한국의 연구에서 이러한 공감의 저하가 나타나지 않은 점은 흥미로운데, 이러한 것은 문화적 요인, 교육과정 차이, 교육환경, 롤모델, 자율성의 차이, 병원의 가이드라인, 보험 규정 등등이 영향을 주는 것으로 보인다.

It is interesting to note that such decline in empathy was not observed in cross-sectional studies of medical students in Japan23 or Korea24 (both studies used the JSPE). The inconsistent cross-cultural findings can be explained by cultural factors, curricular differences, educational experiences, role models, caregivers’ autonomy, hospital guidelines, health insurance regulations, and the tradition of the patient’s utmost respect for the physician. 

이 연구가 일개 사립 대학의 연구이고, matched cohort가 전체의 27%밖에 안되는 것도 한계점이다. 그렇지만 우리 대학은 다른 미국의 큰 사립대학과 여러 측면에서 유사하다.

It is important to note that our findings may be limited by the fact that our study sample was from one private medical school, and the matched cohort represented only 27% of the total cohort. These limitations, however, are somewhat mitigated by the fact that our medical school is similar to other large private medical schools in the United States in regard to its four-year curriculum, composition of student body, attrition rate, and career choices. 

또한 matched cohort의 평균이 나머지 cohort의 평균과 비슷한 점도 의미가 있다.

In addition, our findings that changes in mean empathy scores for the matched cohort mirrored those for the rest of the cohort suggest that the statistically significant results found in the matched cohort can be applicable to the total study participants as well. Of course, generalization of our findings can be enhanced by replicating this study in other medical schools in the United States and abroad.

결론

Conclusions

점차 태도가 시니컬해지고, 이상주의가 쇠퇴하는 것은 오래 전부터 알려져왔다. 

The escalation of cynicism and atrophy of idealism has long been recognized as part of students’ socialization in medical school and their adaptation to a professional role.51 This downward trend has also been observed in the ethical erosion of medical students during their clinical training.52 

Hafferty는 이것을 '사회화된 기억상실'이라고 명명했다. 일부 학생들은 소크라테스선서를 통해서 그러지 않겠다고 했음에도 불구하고 자신도 모르는 사이 '비공감적 특성'을 학습한다. Novak은 마치 멸종위기에 처한 종 처럼 사라져간다고 비유했다.

Hafferty53(p 18) described this transformation as a form of “socialized amnesia” in which some medical students unwittingly acquire the unempathic quality they pledge not to adopt in the Socratic Oath. The unfortunate trend of the erosion of empathy in medical students reminds us of a gloomy remark by Novak54 that empathy in medical education often fades away like an endangered species. To prevent extinction of this valuable human quality, we need to make profound changes in medical education by developing targeted educational programs at the undergraduate, graduate, and continuing medical education levels. 

여러가지 전략이 가능할 것이다. 다음의 10가지 전략이 있다.

There are different approaches that can be implemented in medical schools to retain and enhance empathy. For example, the following 10 approaches have been described55 to enhance empathy in medical education: 

improving interpersonal skills, 

analyzing audio- or video-taped encounters with patients, 

being exposed to role models,

role-playing (aging game), 

shadowing a patient (patient navigator), 

experiencing hospitalization, 

studying literature and the arts, 

improving narrative skills, 

watching theatrical performances, and 

engaging in the Balint method of small-group discussion. 

또한 롤모델, 환자, 환경에도 신경을 써야 한다.

It is also important to pay attention to the importance of role models, patients, and the environment in which care is given.

학생들은 이러한 외적 요인을 신경써야 한다. 무례한 환자를 초반에 만나지 않도록 하는 간단한 개입만으로도 도움이 될 수 있다.

Students should be reminded of the effect of these extrinsic factors on the quality of care they will render to their patients. Sometimes simple interventions such as not exposing students to disrespectful patients at the beginning of their clinical training could be helpful in retaining students’ empathic orientation toward patient care.

의학교육 기간동안 공감이 크게 변한다는 것을 신경쓸 필요가 있다. 이것은 신경 쓸 수 도 있고 안쓸 수도 있는 문제가 아니라 반드시 신경을 써야 하는 문제고, 의학교육을 하는 모두가 공감을 강조하지만 단순히 주창만 하고 진정으로 포용하지 않는 것, 그리고 그것을 향상시키기 위한 프로그램이 없는 것 등은 다른 사람들은 전혀 좋아하지 않을 노래를 부르는 것과 같다. 

Profound changes to enhance empathy during medical education should be considered by leaders in medical education as a mandate, not an option, if the public is to be served in the best possible manner.55 Most of us in medical education advocate empathy, but the effect of simply advocating empathy without embracing it and living with it, and without implementing targeted programs to enhance it, is analogous to singing a lovely song only in one’s own mind without others ever enjoying it!55 Tangible changes in medical education outcomes can be made by actual implementation of targeted programs, not by simply advocating good ideas.