공생적 의학교육(symbiotic medical education)의 경험적 근거 : 지역사회 기반 프로그램과 3차병원 기반 프로그램의 비교분석

Empirical evidence for symbiotic medical education: a comparative analysis of community and tertiary-based programmes

Paul Worley,1 David Prideaux,2 Roger Strasser,3 Anne Magarey4 & Robyn March1

Introduction

지난 20년간 학부 의학교육의 한 부분으로서 지역사회에서 학생교육을 시켜야 한다는 것이 점차 강조되었다. 이러한 것을 가속시킨 몇 가지 요인들이 있다. (국제보건전략, 의료인력, 3차병원의 사례 변화, 의학교육에서 generalism의 중요성)

Over the last 2 decades, there has been an increasing emphasis on students learning in the community as part of their undergraduate medical education. This has been driven by a number of factors, including global health strategies,¹ workforce imperatives,² changing caseloads in tertiary hospitals³ and recognition of the importance of generalism in medical education.⁴

1997년 Flinders University는 PRCC라는 농촌에서의 general practice를 기본으로 하는 1년짜리 교육과정을 시작하였다. 1년에 최대 16명 학생을 대상으로 (전체 70~90명 학생) 3학년 전체를 애들레이드에서 200~500km 떨어진 농촌에서 진료를 하면서 학습하도록 한 것이다. 나머지 학생은 아델레이드 도심의 3차병원에서 교육을 받는다.

In 1997, Flinders University commenced an innovative year-long clinical curriculum based in rural general practice, the Parallel Rural Community Curriculum (PRCC),⁵ designed to meet these objectives. The PRCC was funded by a special grant from the Australian Government as part of a comprehensive rural medical workforce strategy.⁶ It enabled up to 16 students per year, out of a class of 70–90 students, to undertake their entire Year 3 studies within rural practice, 200–500 km from Adelaide. Their peers undertook their Year 3 study at Flinders Medical Centre (FMC), the university's urban tertiary teaching hospital in Adelaide.

의학과3학년은 총 4년의 graduate-entry course 중 임상실습을 하는 2년 중 첫 번째 학년이며, FMC에서는 외과, 내과, 소아과, 여성건강의학, 일차의료(general practice), 정신과학 등을 순차적으로 로테이션 하게 된다. PRCC학생들은 같은 내용을 1년간 지역사회 기반 프로그램을 통해 학습하며, 이 학년이 끝난 후 모든 학생들은 학년말 시험을 치르게 된다.

Year 3 is the first of 2 clinical years in the 4-year graduate-entry course at Flinders University. At FMC it is studied through sequential rotations in surgery, internal medicine, paediatrics, women's health, general practice and liaison psychiatry. The PRCC students study the same content in a year-long community-based programme. At the end of this year, all students sit the final major clinical examination in the course.

PRCC는 다른 문헌에서 더 자세히 다뤄진 바 있으며, 이전 연구에서 PRCC 학생들은 3차병원에서 실습을 한 다른 학생들에 비해서 더 나은 성적을 보여준다는 것이 보여진바 있다. 

The PRCC is described in detail elsewhere.⁵ It has been previously shown that PRCC students have improved examination performance in comparison with their tertiary hospital-based peers.⁷ This study was designed to explain the differences in the teaching context, from the students' perspectives, between the tertiary hospital and community-based programmes.

Methods

This study was undertaken from an interpretivist perspective using a case study methodology.⁸ All 6 students who participated in the PRCC in 1998 were included in the study, along with 16 peers from FMC selected to match for age, gender, and residential and academic backgrounds. Data were collected through structured interviews with the students in weeks 22 and 35 of the 40-week Year 3, with a further interview carried out during the following year. All interviews were tape-recorded, transcribed anonymously, and entered into an electronic database to allow for coding and thematic analysis using nud*ist software. Analysis of the transcripts was undertaken separately by 2 of the authors (PW and RM), with agreement on the findings reached by discussion and by checking with the interviewer (AM) and the students. Final organisation of the findings was based on discussion by all authors. Two authors, PW and DP, were involved in the development of the PRCC programme. At the time of this study, AM and RM were independent research assistants at the School of Medicine at Flinders University, and RS led rural medical education at a separate Australian university.

Data from these 3 sets of interviews are referenced in this article as ‘(Xy.z)’, where ‘X’ refers to the site (R = Riverland, F = FMC), ‘y’ refers to the particular student (1–6 at Riverland, 1–16 at FMC), and ‘z’ refers to the 3 sets of interviews (1 = June 1998, 2 = October 1998, 3 = 1999).

Results

These data describe the teaching/learning environment in which the 3 groups of students undertook their Year 3 study in 1998. Several themes and sub-themes were found within the data (Table 1).

임상 요인 

Clinical factors

This theme related to the success with which the 2 programmes meaningfully integrated the student into the doctor−patient relationship.

참여 및 실습

Participation or practice

‘Okay, it's your patient. What are you going to do?' (R1.2)

‘When I think of diabetes, I can picture this patient that I’ve seen and how we treated them.' (R4.1)

‘I don’t think I've ever been in a situation in which I've had the morals and ethics of my own tested, because … I'm a spectator.' (F12.1)

Importantly, when describing patients, the tertiary-based students never once used the possessive ‘my’ or ‘our’, as described above, but rather referred to ‘a’ or ‘the’ patient(s).

환자와의 접촉 / 동료와의 경쟁

Patient contact or competition with peers

‘…outside of the hierarchical system … whenever anything happens I’m involved, and so I can see a lot more.' (R2.1)

In contrast, the desire to have less competition for patients was a common theme of the tertiary-based students (F12.1, F16.1, F9.1, F13.1, F11.1). One student complained of not having delivered a baby during the entire obstetrics term (F13.1). Students were especially critical of their ward round experience and the inverse relationship between patient load and bedside teaching (F16.1, F4.3).

협력 및 위계 관계

Collegiate or hierarchical supervision

Students commented on the willingness of their teachers to reflect on why they practise as they do. From the following descriptions, there appeared to be a collegiate relationship between the community-based students and their supervisors, compared with a more hierarchical relationship at the tertiary hospital. The intensity of these feelings often took the students by surprise. Interestingly, the more collegiate model appeared to be enjoyed by the supervisors too (R6.1).

A tertiary-based student commented:

‘…some people say, “I always do this,” and then you’ll say, ‘Why?’ and they'll say, ‘Just because I do!”’ (F3.1)

In contrast, a community-based student reported that:

‘…they’re all pretty happy to be – not contested, but challenged, you know. If we've learned something and we say to them, “Why are you doing it that way?” they're quite happy to say, “Well, it's probably not the way you should do it. You'd better do it the right way”.' (R5.1)

A key factor leading to this relationship was the perceived staff : student ratio (R2.1, F16.1). The community programme had fewer students for each designated teacher. This resulted in one community-based student stating:

‘…if you don’t turn up for a day then you get missed here…whereas you can get lost in the hospital system.' (R1.1)

The latter was confirmed by one of the tertiary-based students, who outlined the potential for ‘slacking off’ when there were 10–12 students on a ward round (F13.1). Although some students enjoyed being challenged by consultants, who, at the same time, obviously cared for the students (F9.3), others felt that the consultants treated them as second-rate people just because they happened to be students, and, consequently, most mentoring and teaching occurred with registrars and interns (F3.1, F5.1). In contrast, one community-based student explained that:

‘…basically I try and aim for what the GPs are able to do…I use them as my sort of goal.’ (R2.1)

기관 요인

Institutional factors

Another theme related to how the presence of the students affected the agenda of the two principal institutions involved in the students' learning environment: the local health service's clinical service agenda and the university's academic agenda.

가치있는 역할 또는 불편한 역할

Valued or inconvenient

The ‘participatory’ learning environment in the community-based programme led to a sense of the students feeling valued by staff at the local hospital. One student reported that:

‘…they love us! I think they see us as reasonably valuable assets to the hospital team.’ (R5.1)

This contrasted with the descriptions of inconvenience put forward by the students at the tertiary hospital, which was regarded as an environment that was too busy for teaching (F3.1). These included comments such as students being: ‘supernumerary’ (F5.1); ‘just tagging along with them’ (F11.1); ‘wander[ing] around behind’(F1.1); ‘hanging around theatre where you can’t see a lot' (F9.1); ‘[being] at the bottom of the pile’ (F13.1), and ‘[being] a very small cog in a very large group’ (F13.1).

통합적 학습 또는 블록 학습

Concurrent learning or discipline blocks

The community-based programme was structured so that its students would arrive at the same curriculum end-point as the hospital-based students, but would get there by a different path of study. This study was based on the patients who ‘walked through the door’ of the general practice.

This integrated learning environment appeared to suit certain students, but not others. The students who chose the community-based programme all saw the autonomy and self-directedness that this arrangement fostered as an advantage, but not all found this easy (R3.1) and some expressed anxiety during the year in regard to whether they would end up with substantial gaps in their knowledge (R1.2), or whether they would have their knowledge organised well enough to pass the examinations (R5.3). The tertiary hospital-based students expressed mixed reactions to this, articulating the preference for concentrated discipline-specific learning as a reason for not choosing the community programme (F3.3).

사회 요인

Societal factors

A further theme identified in the data related to how the students' presence was viewed by the community and how students learned to appreciate the wider community needs.

해결의 일부분 또는 문제의 일부분

Part of the solution or part of the problem

The clinical environment in each location was described consistently as strained and understaffed. However, the community-based students recognised themselves as being part of the solution to this problem and had this reinforced by their medical supervisors:

‘…we’re another pair of hands'(R5.1) and ‘…we relieve the load’(R1.1).

One student remarked that their patients shared this view:

‘…the majority of people are really keen for more country doctors…they really see you as a doctor to be…and they just say, “Oh gee, will you come back? Are you going to be a country doctor?”’ (R6.1)

The tertiary hospital-based students, on the other hand, emphasised the extra burden they placed on patients (F16.1) and staff (F3.1, F1.1, F13.1, F4.1). One student summarised their feelings by saying:

‘…students won’t go and examine a patient who we know has been examined 10 times, and we know that we're not helping them.' (F16.1)

지속적 접근 또는 단면적 스냅샵

Longitudinal access or short-term snapshot

The community-based students consulted individual patients repeatedly throughout the year, often at different sites (hospital, clinic, theatre, home) and at different stages of their illness (R1−6.1). This proved to be a powerful personal and professional experience. One student commented:

‘…some of them sort of creep up on you and you get attached to them and then they do something silly like dying…they sort of want you to come and have morning tea or offer you the week on the houseboat, or “When your husband's up can you come for dinner?”' (R5.1)

Sometimes this resulted in patient-initiated contacts, to such an extent that one student reported being double-booked and that they:

‘…actually felt like a doctor…I had to make someone wait 5 minutes.’ (R4.1)

In contrast to these experiences, the tertiary hospital-based students did not once mention continuity, or the importance of understanding a patient's cultural background, during their interviews in Year 3.

개인 요인

Personal factors

The final theme identified brought together data that related to the personal and professional issues learned through their experience.

지속적 멘토 또는 다양한 감독관

Continuity mentors or various supervisors

‘…showing an interest and remembering your name. I think that's one of the big things that really strikes you – if a clinician actually remembers your name from one tutorial to the next and shows an active interest in your learning then it's a lot easier to learn – you're more inclined to learn in that particular setting than if you are just another faceless medical student.'(F6.1)

일 또는 공부

Work or study

In each of their interviews, the community-based students consistently referred to ‘going to work each day’, reflecting a sense of vocation in their day-to-day learning activities (R1−6.1, R1−6.2, R1−6.3). The tertiary students never used the term ‘work’. Instead, they referred to the particular discipline/term they were studying. They described ‘learning’ (F5.1) from doctors, rather than ‘working’ (R1.3) with them.

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Med Educ. 2006 Feb;40(2):109-16.

Empirical evidence for symbiotic medical education: a comparative analysis of community and tertiary-basedprogrammes.

Worley P1, Prideaux D, Strasser R, Magarey A, March R.

Author information

Abstract

BACKGROUND:

Flinders University has developed the Parallel Rural Community Curriculum (PRCC), a full year clinical curriculum based in rural general practice in South Australia. The examination performance of students on this course has been shown to be higher than that of their tertiary hospital-based peers.

AIM:

To compare the learning experiences of students in the community-based programme with those of students in the tertiary hospital in order to explain these improved academic outcomes.

METHOD:

A case study was undertaken, using an interpretivist perspective, with 3 structured interviews carried out over 2 academic years with each of 6 students from the community-based programme and 16 students from the tertiary hospital. The taped interviews were transcribed and analysed thematically using NUD*IST software.

RESULTS:

The community-based programme was successful in immersing the students in the clinical environment in a meaningful way. Four key themes were found in the data. These represented clear differences between the experiences of the community-based and hospital-based students. These differences involved: the value that students perceived they were given by supervising doctors and their patients; the extent to which the student's presence realised a synergy between the work of the university and the health service; opportunities for students to meet the aspirations of both the community and government policy, and opportunities for students to learn how professional expectations can mesh with their own personal values.

CONCLUSION:

This study has provided empirical evidence for the importance of the concept of symbiosis in understanding quality in medicaleducation.

Comment in

• Clinical education: context is everything. [Med Educ. 2006]

PMID:

 

16451237

 

[PubMed - indexed for MEDLINE]