의대생의 불안 : 성숙도의 차이나 의대/의전원 입학에 따라 임상실습에 대비하는 불안감에 차이가 있는가?

Anxiety in medical students: is preparation for full-time clinical attachments more dependent upon differences in maturity or on educational programmes for undergraduate and graduate entry students?

K Hayes, A Feather, A Hall, P Sedgwick, G Wannan, A Wessier-Smith, T Green & P McCrorie

Introduction

의과대학생에게 있어서 불안과 스트레스는 언제나 있어왔으며, 여기에는 임상실습으로 이행하는 과정의 불안감도 포함된다. 최근의 질적 연구 결과를 보면, 이러한 이행 시기가 특히 더 스트레스를 유발하는 것으로 나타난다.

Anxiety and stress have long been identified in medical students,1,2 including anxieties specific to the change to full-time clinical studies.3 A recent qualitative study has again highlighted these transition periods as being particularly stressful for students.4

대부분 교육과정에서 첫 2년(1학년, 2학년)에도 기초의학과목과 임상경험을 통합한 형태의 교육이 이뤄지고 있으나, 전일제(full-time)으로 임상현장에 있는 것은 매우 흥미진진하면서도 걱정이 되게 만드는 상황이다. '학생 중심'에서 '환자 중심'으로 교육의 초점이 이동하게 되고, 그리고 지금까지의 익숙한/구조화된/안전한 교육환경은 덜 조직화되고 가끔은 intimidating한 임상 현장으로 변화하게 된다. 추가적으로 학생들은 임상술기를 익히고 보일(demonstrate)줄 알아야 한다.

Although there is some integration of basic medical sciences and clinical contact in the first 2 years of most courses, the transition to full-time clinical attachments can be both an exciting and a worrying time for students. The focus of the educational process changes from being student- to patient-centred and the previously familiar, structured and safe learning environment changes to that of the less organised and often intimidating clinical arena. In addition, students are challenged by the need to acquire and regularly demonstrate clinical skills, including history taking, examination, giving information and performing practical procedures.

임상술기에 대한 introductory 과정이 스트레스와 불안을 줄여주는 것으로 나타나지만, 이 시기에 학생이 스스로 얼마나 준비되었다고 느끼는지에 영향을 주는 요인에 대한 연구는 적다.

Introductory clinical skills courses have been shown to reduce stress and anxiety5 but there is little in the literature about what influences how prepared students feel during this time.

의학전문대학원 프로그램은 영국에서 빠르게 확산되기 시작하였으며, 전통적인 의과대학 과정과는 다르다. GEP는 PBL과 같은 다른 교수법을 사용하는 경향이 많고, 더 기간이 짧으며, 더 임상적으로 관련된 교육과정을 다르고, 임상과 의사소통 기술을 완전히 통합한 프로그램을 운영한다. 이러한 변화는 학생들이 '임상적으로 준비될 수(clinically prepared)' 있도록 하는 목적이 있는데, 특히 GEP학생들이 3년의 임상실습 경험을 쌓는 의과대학 학생들과 달리 2년간밖에 시간이 없기 때문이기도 하다. 이러한 변화와 동시에 GEP에 참여하는 의과대학에는 인력과 재정에도 큰 영향을 주었다.

Graduate entry programmes (GEPs) are expanding rapidly in the UK and differ considerably to long-established traditional undergraduate courses; GEPs tend to involve different methods of delivery (e.g. problem-based learning), shorter and more clinically relevant curricula and fully integrated clinical and communication skills programmes. These changes are chiefly designed to make students more clinically prepared at all stages of their training, particularly as GEP students only have 2 full clinical years (versus 3 for undergraduates). Alongside the changing educational culture there have also been considerable staffing and funding implications for participating medical schools.

This paper examines student perspectives of the positive and negative influences leading up to this transition and compares the levels of anxiety and specific anxieties experienced by 2 sets of students at a London medical school.

Are we simply achieving the same outcome in different ways or do GEP students really feel better prepared for full-time clinical studies than their undergraduate (UG) colleagues? And if so, what are the most important factors?

Background

St George's Hospital Medical School (SGHMS) has been running parallel UG and GEP MBBS courses since 2000. The 2 courses have markedly different entry criteria, resulting in different student characteristics. 

• The UG course is dominated by students entering after their A-levels (or equivalent examinations), but includes a few university graduates (5%), all of whom have completed a science degree or higher qualification. Students on the UG course are expected to graduate in 5 or 6 years. At the time of the study their median entry age was 19 years.
• The graduate entry programme (among the first in the UK) reflects the UK government's determination to increase the number of UK graduating doctors in keeping with the European Working Time Directive.6 The students are unique in that they may hold any university degree (2 : 2 and above), but are selected primarily on their performance in the GAMSAT (Graduate Australian Medical Schools Admission Test) assessment7 and a structured interview. They are expected to graduate in 4 years. At the time of the study, their median age on entry was 25.5 years. The 2 courses run in parallel and are based on different educational models.

• The UG course is a relatively traditional systems-based course delivered in the early years predominantly by lectures and illustrative clinical case scenarios. 
• The GEP course is delivered using problem-based learning (PBL) cases (New Mexico PBL model) and uses contextualised learning8 wherever possible, integrating clinical skills throughout the first 2 years. Central to the learning process is revisitation of material based on Harden et al.'s spiral curriculum.9 
• The UG course, whilst introducing some early clinical skills, focuses on a 3-week Introduction to Clinical Practice (ICP) programme at the beginning of Year 3. Despite these differences, both courses will share the same finals assessment with a view to fitness to practise.

Statistical analyses

Statistical analyses were performed using spss Version 10. As distributional assumptions could not be made, students on the 2 courses were compared in age using the Mann–Whitney U-test (test statistic approximated to the normal distribution and denoted by z). Distribution of gender was compared between courses using the chi-squared test (test statistic denoted by ÷2). The 2 courses were compared on the 13 statements of anxiety using the Mann–Whitney U-test (test statistic approximated to the normal distribution and denoted by z). All reported P-values are 2-sided and given to 3 significant decimal places. The critical significance level was 0.05. A large number of significance tests were conducted overall but because of type I errors the results of such tests are difficult to interpret. No doubt these multiple statistical tests are correlated and the Bonferroni correction factor is inappropriate as it is conservative and may miss real differences.10,11 Therefore, a subjective approach was applied. More weight was given to comparisons yielding very small P-values than those close to the 5% significance level.

A total anxiety score was derived for each student by summing the student's scores across the 13 anxiety statements, with higher scores reflecting less anxiety. For questions 3, 10, 11 and 12, the scores were reversed because the questions were phrased negatively. An analysis of covariance was undertaken in which total anxiety was regressed on gender, course and age. The type III sum of squares was reported for each main effect and the associated significance test was therefore adjusted for all other main effects. A histogram of the residuals verified the assumption of normality.

Two open questions allowed students to discuss both negative and positive aspects that may have influenced them. Two authors (KH and AF) individually reviewed all free text comments and grouped them qualitatively into common recurring themes. We then compared our groupings and agreed on the main common themes. We selected certain individual comments that best reflected student feelings.

Results

• Demographic data

• Anxiety statements

• Analysis of covariance

Discussion

불안과 스트레스에 대처하는 방법을 익히는 것은 매우 중요하며, 긍정적 측면도 있을 수 있다. 그러나 과도하면 문제가 될 수 있고 여기에 영향을 주는 요인을 이해할 필요가 있다.

Learning to deal with anxiety and stress is an everyday part of a doctor's working life. 

• Indeed, anxiety and stress can have a positive influence, particularly with assessment, as an overly relaxed attitude may lead to complacency and a lack of work.13 
• However, excessive stress and anxiety may lead to poor assessment performance and clinical skills acquisition.14 

Clearly, factors that may ultimately lead to deficiencies in clinical performance and possibly in patient care need to be prevented wherever possible.

핵심 질문은 불안점수 총합이 나이 때문인가, 아니면 교육과정 때문인가 하는 것이다.

The key question is whether the significant differences in total anxiety scores were simply due to increased GEP maturity (on average 6.5 years older), or to the differences in curricula design (PBL versus non-PBL) and the markedly different clinical skills teaching programmes.

성인학습이론에 따르면 더 나이가 많을 수록 학습에 대한 접근 방법이 달라진다고 본다. 의학전문대학원으로 들어온 학생들이 더 동기부여가 잘 되어있고, 학습 기술이 더 성숙하며, 자기주도성이 강하고, 더 많은 삶의 경험을 가지고 있다. 그러나 부정적인 요소도 있는데 고착화된 학습법을 사용할 수 있고, 경제적 문제에 더 신경을 쓸 수도 있고, 과학 배경지식이 약할 수 있다.

Adult learning theory assumes that older students will be mature in their approaches to learning.15 Graduate entry students have potentially higher motivation (career change and self-funding issues), more mature learning skills, increased self-direction and more ‘life experience’.15 However, some negative factors include fixed learning approaches, greater financial concerns16 and a limited scientific background at enrolment.8

나이를 보정하고도 불안 정도에는 차이가 있었다. 따라서 성숙도가 두 그룹 사이에 차이를 주는 요인은 아니라고 할 수 있다.

A significant difference between courses in student anxiety levels persisted after adjusting for age. It would appear, therefore, that maturity is not the main factor contributing to differences between the 2 groups.

이렇게 연관성이 없다는 것이 영국에서 의학전문대학원 체제가 확장되고 있는 것을 지지하는 근거도 반대하는 근거도 아니다. 그러나 최근 Norman이 지지한 성인학습이론에 의문을 던질 수는 있는데, Norman은 주로 차이를 만드는 것은 학습환경이지 학습자의 내재적 차이가 아니라고 하였다.

This lack of association neither supports nor detracts from the growth of graduate entry in the UK. It does, however, cast further doubt on the support for adult learning theory recently championed by Norman,17 who considers it to be the learning environment that makes the main difference rather than any intrinsic differences between learners.

성별 분포는 양쪽에서 비슷하였기 때문에 차이를 설명하지 못한다. 그러나 남성이 여성보다 불안감을 덜 느끼는 것으로 나타났으며 이전 연구와도 부합하는 결과이다.

Gender distribution was similar on both courses, so this does not explain the differences either. Interestingly, however, men expressed significantly less anxiety compared to women, in keeping with reports in previous literature comparing male and female medical students.18

GEP의 integrated practical and communication skills 

The GEP course provides fully integrated practical and communication skills throughout the first 2 years, compared to mainly the ICP programme on the UG course. The previously well supported acquisition, practice and continuous assessment − arguably the most important factor − of skills may have left the GEP students feeling significantly more confident in this area, as was borne out in their free text responses. The support and enthusiasm of teachers has previously been identified as a major influence on student acquisition of clinical skills.19 Interestingly, staff support was more important for GEP than UG students and the much smaller GEP cohort probably made it easier for students to form closer relationships with teaching staff.

Conversely, peer support was more often identified by UG students as helping to relieve anxiety, in keeping with reports of other undergraduate studies.20

These results suggest that early integration of clinical skills, placed in context, well supported by clinical and communication skills teachers, with appropriate assessment, are essential elements of a modern medical school curriculum.

영국 의대생을 대상으로 한 조사에서 거의 40%가까운 학생이 건강상이나 개인상 이유로 학교를 떠난다고 했는데, 현재 이러한 문제에 대한 지원은 UG모델을 기반으로 하면서, GEP에서도 동일하게 적용될 것이라고 가정하는 경우가 많다. 그러나 본 연구결과 두 그룹은 상당한 차이가 있는 것으로 보인다.

One UK study of medical student wastage reported nearly 40% leaving due to poor health (particularly psychological) and personal problems (many related to course stressors).21 A recent review of the literature concerning stress management in medical education concluded that there was proven benefit for students who used available methods of support.22 Much of the current provision is based on UG models and assumes that graduate entrants need the same resources. As there are major differences between the 2 groups, it may be that a more tailored approach to personal support is required for each of them.

Hill et al.,23 examining whether junior doctors felt prepared for hospital practice, found that non-traditionally (PBL) taught medical students expressed greater confidence around communication and general clinical aspects of care than those who had been taught traditionally. They attributed these differences to different student selection processes, learning processes and curriculum content. We intend to follow these students to see how they feel on starting work as house officers in order to establish whether the differences persist.

Conclusion

Running 2 parallel MBBS courses in 1 institution has allowed us to directly compare the factors affecting the development of differently prepared future doctors.

Clearly, universally agreed learning outcomes include the development of clinical skills and a professional approach to real patients.24 In order for students to master and maintain these core attributes they need exposure, practice and assessment, introduced as early as possible, and continued until graduation25 and beyond, fostered by a curriculum that ingrains a desire for lifelong learning. It would appear likely that this is more important than any individual student characteristics.

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Med Educ. 2004 Nov;38(11):1154-63.

Anxiety in medical students: is preparation for full-time clinical attachments more dependent upon differences inmaturity or on educational programmes for undergraduate and graduate entry students?

Hayes K1, Feather A, Hall A, Sedgwick P, Wannan G, Wessier-Smith A, Green T, McCrorie P.

Author information

Abstract

INTRODUCTION:

The transition to full-time clinical studies holds anxieties for most medical students. While graduate entry medical education has only recently begun in the UK, the parallel undergraduate and graduate entry MBBS courses taught at our school allowed us to study how 2 differently prepared groups perceived this vital time at a comparable stage in their training.

METHOD:

An anonymous questionnaire collected demographic data and graded anxiety in 13 statements relating to starting full-time clinicalattachments. Two open questions allowed free text comment on the most positive and negative influences perceived during this time. Both a statistical analysis and a qualitative assessment were performed to compare the 2 groups of students.

RESULTS:

The 2 groups were similar with respect to gender but the graduate entry students were significantly older. The graduate entry students were significantly less anxious about most aspects of the transition period compared to the undergraduates. These course differences remained after adjusting for age and sex. When adjusted for course and age, male students expressed less anxiety. The main positive qualitative statements related to continual clinical and communication skills training in the graduate entry group. The main qualitative concerns in both groups related to 'fitting in' and perceived lack of factual knowledge.

DISCUSSION:

These data support the early introduction of clinical skills teaching, backed up by a fully integrated clinically relevant curriculum with continued assessment, in preparing students and reducing levels of anxiety before they start full-time clinical attachments. These course designdifferences appear to be more important than any differences in maturity between the 2 groups.

PMID:

 

15507009

 

[PubMed - indexed for MEDLINE]