학부의학교육과 의사 프로페셔널리즘의 토대(JAMA, 2015)

학부의학교육과 의사 프로페셔널리즘의 토대(JAMA, 2015)

Undergraduate Medical Education and the Foundation of Physician Professionalism

Darrell G. Kirch,MD Association of American Medical Colleges,Washington, DC.

Maryellen E. Gusic, MD Association of American Medical Colleges,Washington, DC.

CoriAst,MHSA Association of American Medical Colleges,Washington, DC.

프로페셔널리즘은 이렇게 정의된다.

Professionalism is the demonstrated “commitment to carrying out professional responsibilities and an adherence to ethical principles”1 

여러 전문직 조직에서 어떻게 의사들의 프로페셔널리즘을 유지할 것인가에 대한 논쟁이 있지만, 학부의학교육에서는 공유거버넌스 모델(shared governance model)이 이 중요한 역량 개발의 프레임워크를 제공한다.

Although there is current controversy regarding how diverse professional organizations should ensure professionalism among practicing physicians, during undergraduate medical education a shared governance model, as described below, provides the framework for developing and accessing this critical competency.

프로페셔널리즘의 토대는 의과대학 이전에 시작된다.

The Foundation of Professionalism Begins Before Medical School

수년간의 개인적 경험을 통해서 의사가 되고자 하는 사람들은 프로페셔널리즘 역량의 토대가 되는 전-프로페셔널리즘을 갖추게 되며, 의과대학 학생선발 과정에서 전-프로페셔널리즘을 평가하는 것이 중요하다.

Aspiring physicians, through many years of personal ex- periences prior tomedical school, establishthe “prepro- fessional” foundation for competence in professional- ism, making it important to assess preprofessional attributes in medical school admissions.

이러한 의사결정의 기반을 이룰 9개의 내적, 대인관계적 역량이 기술된 바 있다.

Providing the groundwork for these decisions, 9 core interpersonal and intrapersonal competencies have been articulated for entering medical students: 

1. ethical responsibility to self and others; 
2. reliability and dependability; 
3. service orientation;
4. social skills; 
5. capacity for improvement; 
6. resilience and adaptability; 
7. cultural competence; 
8. oral communication;and 
9. teamwork.2

이러한 개인 역량들은 대부분의 의과대학에서 임상실습 뿐 아니라 이후의 진료의 성공을 예측하는 요인임이 밝혀졌다.

Importantly, these personal competencies for entering students have been shown to be predictive of success at the majority of medical schools, both in clinical rotations and later in practice.2

이들 전-프로페셔널리즘 역량의 개발에 기여하는 경험들은 학생의 가정과 지역사회 맥락에서 발생하며, K-12, 학부, (종종) 대학원 교육에서 더 강화된다. 추가적으로 점차 '비전통적' 지원자가 늘어나고 있는데, 이들은 봉사경험이 있거나 해당 분야에서 근무한 적이 있어서 더욱 강화된 전-프로페셔널리즘 특성을 지니고 있다.

The experiences that contribute to the development of these preprofessional competencies occur initially within the context of a student’s family and community and,hopefully, are reinforced by experiences in K-12, under-graduate, and(in some cases) graduate education. Inad-dition, increasing numbers of applicants are “nontradi-tional,” having had work or service-oriented experiences prior to medical school that enhance preprofessional at-tributes.

의과대학 입학 후에 강화되는 프로페셔널리즘

Admission to Medical School Reinforces the Commitment to Professionalism

전-프로페셔널리즘 역량에 대한 평가는 의과대학에서 "전인 평가"의 핵심이다.

The evaluation of preprofessional competencies is central to the “holistic review” of medical school applicants.

의과대학 학생선발 절차의 중심에는 MCAT이 있는데, 이 MCAT은 최근 21세기 의사에게 필요한 더 광범위한 포트폴리오를 요구하는 방향으로 수정되었다.

Central to the admissions process, the Medical College Admissions Test (MCAT) has recently been revised to emphasize the broader portfolio of skills required by physicians in the 21st century. 

개정된 MCAT은 다른 몇 가지 선발절차의 변화와 동반되고 있는데, 그 중 하나는 추천서 작성에 대한 가이드라인을 만든 것이다. 또한 표준화된 지원서 양식을 통해 학사 학업내용 뿐 아니라 관련된 개인 경험을 기술하도록 하였다.

The revised MCAT has been coupled with other changes in the admissions process, including the creation of guidelines for letters of recommenda- tion to ensure inclusion of information about the core competencies for entering medical students and, in the standardized application form, asking applicants to document relevant personal experiences in addition to their coursework.

도입 초기이지만 MMI는 의과대학 수행능력을 예측하는 것으로 보인다.

In early stages of implemen- tation, MMIs appear predictive of future performance in medical school.4

아직 미국 내에서는 검토단계이지만 SJT는 벨기에 의대생 선발에서 1997년부터 사용되어왔다.

Although still under assessment in the United States, an SJT has been used by Belgium for medical school admission since 1997.2

학부의학교육에서 프로페셔널리즘 강조하기

Promoting Professionalism Within Undergraduate Medical Education

점차 프로페셔널리즘은 임상 세팅에서 롤모델을 하는 것 만으로 형성되는 것이 아니며, 초기부터, 지속적으로, 교수법과 경험학습을 정교하게 활용하여야 형성된다. LCME 인증 기준은 의과대학이 프로페셔널리즘을 기를 수 있는 학습환경을 만들어야 함을 공식화한다.

Increasingly, it is recognized that professionalism is not cultivated solely by role-modeling in clinical settings but rather that pro-fessionalism must be taught early, longitudinally, and deliberately using both targeted instruction and experiential learning. The LCME accreditation standards formalize the institutional responsibility by requiring that medical schools maintain a learning environment that cultivates the development of professionalism among learners. 

중요한 점은, 한 학생이 전문직으로 성장하는 것에 대한 책임은 행정, 교수, 학생이 모두 공유하는 것이다.

Importantly, this responsibility for students’ professional development is shared with administrators, faculty, and students serving on various administrative committees.

프로페셔널리즘 평가를 위해서 절반 이상의 미국과 캐나다 의과대학은 다음에 의존하고 있다.

To support these assessments, more than half of medical schools in the United States and Canada rely on 

“defined, written standards of non-cognitive behavior, [including] 

• honesty; 
• professional behavior; 
• dedication to learning; 
• professional appearance; 
• respect for law and others; 
• [and adherence to standards related to] confidentiality; and 
• [lack of issues related to] substance abuse,” 

in addition to the academic standards for promotion established by each school.6 

프로페셔널리즘 평가는 생화학 지식 평가보다는 덜 정확할지 모르나, 다양한 도구들이 있다.

Although assessing competence in professionalism may be less precise than assessing competence in the knowledge of biochemistry, today there are tools to assess professionalism in students, including 

• patient evaluations, 
• self and peer assessments, 
• behavioral observation, 
• psychological testing, and 
• even structured examinations.6

학생의 진급을 평가하는 위원회가 물론 기준에 따라야 하나, shared obligation이 있다.

While promotion committees have formal responsibility for adherence to standards, identifying deficiencies in professionalism is a shared obligation among individual faculty educators and extends throughout medical school

전문직 양성에 성공 모델로서의 공유거버넌스

Shared Governance Is a Successful Model for Professional Formation

"한 아이를 키우는데는 한 마을이 필요하다"라는 말이 있듯, 이는 의사를 양성하는 것에도 마찬가지이다. 

The dictumthat “it takes a village to raise a child” also appears to be true of educating a physician. Although the ultimate responsibility for professionalism rests with the physician aspirant, multiple parties are involved in shaping the preprofessional attributes of aspiring physicians, as well as those in the undergraduate process of training, including 

committees for admissions, curriculum, and progression that engage administrators, faculty, and students in the oversight, development, and assessment of professionalism. Affiliated organizations, including the LCME and AAMC, play a significant role in setting standards and providing tools related to teaching and assessing professional development.

4. Pau A, JeevaratnamK, Chen YS, Fall AA, Khoo C, Nadarajah VD. The Multiple Mini-Interview(MMI) for student selection in health professions training—a systematic review. Med Teach. 2013;35 (12):1027-1041.

6. Boon K, Turner J. Ethical and professional conduct of medical students: review of current assessment measures and controversies. J Med Ethics. 2004;30(2):221-226.

---

JAMA. 2015 May 12;313(18):1797-8. doi: 10.1001/jama.2015.4019.

Undergraduate medical education and the foundation of physician professionalism.

Kirch DG1, Gusic ME1, Ast C1.

Author information

• 1Association of American Medical Colleges, Washington, DC.

PMID:

 

25965213

 

[PubMed - indexed for MEDLINE]