의학사의 교육과 멘토링: 오슬러리안 관점(Acad Med, 2013)

의학사의 교육과 멘토링: 오슬러리안 관점(Acad Med, 2013)

Perspective: Teaching and Mentoring the History of Medicine: An Oslerian Perspective

Charles S. Bryan, MD, and Lawrence D. Longo, MD

 

여기서 우리는 의학사 교육을 의-프로페셔널리즘을 발전시키기 위한 한 가지 방법으로서 초점을 맞추고자 한다. 우리가 기본적으로 가지고 있는 관점은, 전문직의 한 사람이라면 - 의료업계의 의사가 아닌 - 자신의 유산을 알고 존경해야 한다는 것이다. professional virtues and values의 한 근원으로서 우리는 Sir William Osler 가 가르치고 멘토 역할을 한 의학의 역사로부터의 교훈을 강조하고자 한다.

In this essay, we focus on the teaching of medical history as one way to foster medical professionalism. Our underlying perspective is that members of a profession, as opposed to practitioners of a trade, should know and honor their heritage. In the discussion that follows, we emphasize one source of professional virtues and values: lessons from the history of medicine as taught and mentored by Sir William Osler (1849–1919).

오늘날 의-프로페셔널리즘을 향상시키는 것은 그 의미가 무엇이든 벅찬 일이다. 우리가 볼 수 있듯 자본주의(with its emphasis on profit)와 정부(with its emphasis on regulation and control)가 추구하는 가치가 프로페셔널리즘(with its emphasis on service to the individual patient and client)의 가치를 손상시키고 있다. 실제로, 어떤 사람들은 프로페셔널리즘을 향상foster하는 것이 그 이유를 상실했다고 말한다. 예를 들어서 '의학을 가르치는 것(“the teaching of medicine” )'이라는 에세이에서 Lancet은 프랑스의 의사학자인 Danielle Gourevitch를 선택했다. Danielle Gourevitch는 "오늘날의 기술중심적technical 그리고 비인간적dehumanized 의학은 전례없는 것이다"라고 말하고, 의과대학생들에게 인문학을 가르치는 것(의사학을 포함하여)은 무의미한 것이며, 왜냐하면 의사의 역할이 곧 헬스케어 기술자health care technician들에 의해서 대체될 것이기 때문이다 라고 하였다. Swick 과 Simpson, 그리고 Krause는 이와 관련하여 '정부와 자본주의가 서구민주주의제국Western democracies을 통틀어서 전문직의 자율성, 가치, 통제를 손상시키고 있다'고 하였다.

Fostering medical professionalism, by whatever means, is a daunting task today. As we see it, the values of capitalism (with its emphasis on profit) and of government (with its emphasis on regulation and control) now undermine the values of professionalism (with its emphasis on service to the individual patient and client). In fact, some imply that fostering professionalism is now a lost cause. For example, for an essay on “the teaching of medicine” to greet the new millennium, The Lancet chose the French medical historian Danielle Gourevitch. Gourevitch1 opined that “today’s technical and dehumanized medicine has no past” and that it is pointless to teach humanities (including, we assume, the history of medicine) to medical students because there will soon be widespread replacement of doctors by health care technicians. Swick and Simpson2 and Krause3 express related views, including the idea that governments and capitalism now undermine professional autonomy, values, and control throughout the Western democracies.

의료전문직이 마주하고 있는 위협에는 다음과 같은 것이 있다.

Current threats to medical profession­ alism include

• (1)의사의 자율성의 손상  damage to physicians’ autonomy by employment models of practice, by government regulations, and by the stipulations of third ­party payers,
• (2)지식에 대한 접근이 어렵다는 의사들의 주장의 침식erosion erosion of physicians’ claims to a difficult­ to­ access body of knowledge by the widespread availability of medical information on the Internet,
• (3)가이드라인이나 표준화된 세트오더로 인한 의사의 개인성individuality의 상실 downplaying of physicians’ individuality by practice guidelines and standardized order sets, and
• (4)기술 발전이 불확실성을 줄여주는 것으로 인하여 야기된 임상판단의 중요성 저하 declining importance of clinical judgment as technological advances reduce uncertainty.

 

일부 사람들은 이전 세대가 알고 있던 의-프로페셔널리즘이 21세기에도 여전히 가능할지 의문을 제기한다. 의료윤리학자 Albert Jonsen이 말한 바와 같이 "노블리스 오블리제의 윤리는 'noble'의 파워가 공격당할 때 흔들리게 된다"

Some observers question whether medical professionalism as known by previous generations will remain possible as the 21st century unfolds. As the medical ethicist Albert Jonsen4 put it, “the ethic of noblesse oblige falters when the power of the noble is attacked.”

윌리엄 오슬러

Sir William Osler

Gourevitch는 SWO를 "고귀함을 가진 의학 일반의 최후의 사상적 거장master thinkier"라고 불렀다. 오슬러는 그의 세대가 "오래된 인문학과 새로운 과학" 사이에서 나타난 긴장을 조화시킬 수 있게 도와주었다. 의학의 역사에 대한 그의 열정을 폭넓은 청중들에게 전달하였고, 의학교육을 향상시켰고, 특히 bedside teaching을 향상시켰다.

Gourevitch1 called Sir William Osler (1849–1919) “the last maître à penser [master thinker] for a noble­minded general medicine.” Osler helped reconcile for his generation the perceived tension between “the old humanities and the new science,”5 conveyed his enthusiasm for medical history to a wide audience, and enhanced medical education, especially by promoting bedside teaching.6

오슬러는 의과대학생들에게 “start at once a bed­side library and spend the last half hour of the day in communion with the saints of humanity.”  라고 말했다. 오슬러의 이러한 말은 광범위한 인간의 우려에 관한 탁월한 사상가들에게 지속적으로 노출됨으로서 “the silent influence of character on character” 를 촉진하기 위한 것이었다. 또한 오슬러는 학생들에게 다음을 강조했다. "우리의 소명의 꽃인 cultivated general practitioner가 되어라. 이것이 당신네들 대부분의 운명이 되기를!" “develop into that flower of our calling—the cultivated general practitioner. May this be the destiny of a large majority of you!”

Osler7 advised medical students to “start at once a bed­side library and spend the last half hour of the day in communion with the saints of humanity.” He sought to promote “the silent influence of character on character” through exposure to eminent thinkers who have addressed a range of human concerns.8 He encouraged students to “develop into that flower of our calling—the cultivated general practitioner. May this be the destiny of a large majority of you!”9

그러나 오슬러는 의과대학 공식 교육과정에 인문학을 넣기 위한 노력을 기울이지는 않았다. 그는 학생들에게 인문학을 스스로 공부하기를 권했다. 아마도 그는 아브라함 플렉스너가 1910년 그랬던 것처럼, premedical 교육이 인문학에 대한 충분한 노출 기회를 제공했다고 생각했을 것이다. 또한 그는 의사학을 포함시키는 것을 지지하지도 않았다. 비록 오슬러가 성공한 의사-역사학자이지만, 1902년 "지금처럼 교육과정이 과포화된 상태에서는 '의사학'을 강제로 필수 과목에 넣는 것이 바람직해 보이지 않는다"라고 했다.

Yet he made no effort to insert the humanities into the formal medical school curriculum. He encouraged students to study the humanities on their own. He probably presumed, as did Abraham Flexner in 1910,10 that premedical education afforded ample exposure to the humanities. Nor did he advocate inserting the history of medicine; although Osler was an accomplished physician–historian, he asserted in 1902, “In the present crowded state of the curriculum, it does not seem

desirable to add ‘the History of Medicine’ as a compulsory subject.”11

의-프로페셔널리즘 촉진을 위한 의사학 교육

Teaching Medical History to Promote Medical Professionalism

어떻게 프로페셔널리즘이 진화해왔는가

How professionalism is evolving

Hafferty and Castellani의 의-프로페셔널리즘 분류법은 오늘날의 젊은 의사들, 소위 X세대와 Y세대 및 그 이후 세대 의사들이(“Generation X” (born between 1965 and 1979), “Generation Y” (born between 1980 and 1994), and beyond) 의사의 고용모델, 기능적 역할functional roles, 라이프스타일 선택에 있어서 점차 더 다양해질 것이라는 가능성을 고려한 것이다.

A proposed typology of medical professionalism by Hafferty and Castellani13 takes into account the likelihood that medical practice for today’s young physicians—members of so ­called “Generation X” (born between 1965 and 1979), “Generation Y” (born between 1980 and 1994), and beyond—will become increasingly pluralistic as physicians’ employment models, functional roles, and lifestyle choices continue to diversify. The terms employment models, functional roles, and lifestyle choices are our brief way of capturing the following ideas:

• 많은 의사들은 점차 더 좁은 전공과 세부전공으로 나누어저 발전할 것이다.
  Many physicians will develop increasingly narrow areas of practice as specialties and subspecialties continue to divide. 
• 많은 의사들은 generalist가 될 것이나, 고용 모델employment model은 무척 다양할 것이다.
  Many physicians will be generalists, but their employment models will vary considerably. 
• 더 많은 의사들이 교대근무shift worker로 일할 것이나, 일부는 선대의 의사들과 마찬가지로 끝이 없는 헌신open ­ended commitments을 유지할 것이다.
  A growing number of physicians will be shift workers, but others will retain open ­ended commitments similar to those of their predecessors. 
• 많은, 아마도 대부분의, 의사들은 헬스케어시스템에 고용될 것이지만, 나머지는 저항할 것이다.
  Many, perhaps most, physicians will be employees of health care systems, but others will resist. 
• 파트타임으로 근무하는 의사들의 숫자가 늘어날 것이다.
  Growing numbers of physicians (especially physician couples with children) will be part­time workers.

프로페셔널리즘의 유형

Types of professionalism

Hafferty and Castellani는 의료-근무의 10가지 핵심 특징을 도출했다. 

Hafferty and Castellani13 identified 10 key aspects of medical work. These are, in alphabetical order,

• altruism,
• autonomy,
• commercialism,
• interpersonal competence,
• lifestyle,
• personal morality,
• professional dominance,
• social contract,
• social justice, and
• technical competence.

 

이 근무의 여러 특징들을 각각의 클러스터로 나눠보자면 일곱 가지 유형의 프로페셔널리즘으로 구분된다.

Arranging these aspects of work within separate clusters, they identified seven types of professionalism:

• nostalgic,
• entrepreneurial,
• academic,
• lifestyle,
• empirical,
• unreflective, and
• activist.

 

일부 선행 연구에 따라서 우리는 의사학을 가르치는 것이 이 일곱가지 중 두 가지 타입의 프로페셔널리즘을 향상시키는데 유용할 것으로 제안한다.

Building on some previous work,14,15 we suggest that teaching the history of medicine may be useful for enhancing two of these types:

• nostalgic professionalism, 전문직의 한 구성원으로서 소속감과 유대감을 강화시키는 것
  which fosters a sense of belonging and solidarity as members of a profession, not a trade, and
• activist professionalism, 과도한 상업화에 저항하는 사회적 책임을 강화시키는 것
  which fosters civic responsibility and opposes excessive commercialization.

 

 

nostalgic professionalism을 향상시키기 위한 의사학 교육

Teaching medical history to promote nostalgic professionalism

과거 세대는 매력적이지만, 누구도 그 세대로 돌아가고 싶지 않을 것이다. 상류층 의사 한 번 만나기 힘들었던 Victorian England 시대의 노동자들의 가혹한 현실.

Previous eras have their attractions, but nobody would want to return to a previous era for their own health care. Consider, for example, Sir Luke Fildes’ iconic painting, The Doctor (1891), in which a well­dressed physician presides over the death of a young girl in a poor fisherman’s cottage. Who could possibly prefer that caring, attentive physician to the gruffest physician on the planet today who brings ceftriaxone to cure the child’s streptococcal septicemia? Also, those who eulogize Fildes’ painting as depicting the quintessential physician– patient relationship—and certainly there is much to be commended in the physician’s bedside body language— overlook the harsh reality that the working classes in Victorian England seldom enjoyed access to upper­class physicians willing to give so freely of their time.17

 

이러한 우려reservation에도 nostalgic professionalism을 발전시켜야 하는 세 가지 이유가 있다.

Despite these reservations, there are at least three reasons to promote nostalgic professionalism.

 

첫째, 학습자는 단순히 헬스케어 테크니션 이상이 되기 위해서는 전문직의 핵심적 이상향, 원칙, 덕목, 특징을 내면화시킬 필요가 있다.

First, and as emphasized by Hafferty18 in his deconstruction of nostalgia, learners need to internalize certain core ideals, principles, virtues, and character traits that are essential if they are to become more than just health care technicians. Osler19 wrote, for example,

시간은 변하였고, 진료 환경은 빠르게 달라지고 있지만, 우리의 선조들에게 영감을 주었던 그 이상향은 여전히 우리의 것이기도 하다. 늘 오래된 것이지만, 동시에 언제나 신선하고 새로운 것이다

The times have changed, conditions of practice have altered and are altering rapidly, but … we find the ideals which inspired them [our predecessors] are ours to­day—ideals which are ever old, yet always fresh and new.

역사와 전통에 대한 감각은 학생들이 좋은 의사가 되기 위해 필요한 자질을 습득하고 갈고 닦을 수 있게 도와줄 것이다. 오슬러의 말을 빌자면 “that which alone can give permanence to powers— the Grace of Humility.”

A sense of history and tradition may help students acquire and hone qualities essential to being a good doctor including, in Osler’s words, “that which alone can give permanence to powers— the Grace of Humility.” 20

둘째, 역사적으로 훌륭한 롤모델들이 있다.

Second, history serves up useful role models.

Osler, a prolific medical biographer, kept above his mantel portraits of three British physicians: Thomas Linacre (c. 1460–1524), William Harvey (1578–1657), and Thomas Sydenham (1624–1689). These physicians symbolized for Osler the literary, scientific, and clinical dimensions of medicine, respectively. Osler called a fourth British physician, Sir Thomas Browne (1605–1682), his “lifelong mentor” because Browne’s Religio Medici (“the religion of a doctor”) informed Osler’s inner life.21 In a recently published treatise on mentoring in academic medicine, Lawrence G. Smith22 writes about today’s needs for such heroes:

 

영웅이 없었다면, 사람들은 자신이 되고자 하는 누군가가 아니라 현재에 머물러 있었을 것이다. X세대와 Y세대를 연구한 사람들이 아쉬워하는 것은, 이들의 세대에는 영웅이 없다는 것이다. 영웅을 발견하고, 그들의 성취를 기뻐하고, 우리의 학습환경에서 그들의 헌신을 늘 볼 수 있게 만들어주는 것이 의학교육에 있어서 중요한 도전과제이다. 영웅은 개개인이 그렇게 되기 위해서 노력해야 하는 궁극적 이미지를 형성한다.

Without heroes, people often settle for who they are instead of aspiring to who they can become. One of the laments of those studying Generations X and Y is that, as a generation, they lack heroes…. The identification of heroes, the rejoicing in their accomplishments, and the commitment to keep them ever visible in our learning environments are among the great challenges to medical education. Heroes form the ultimate image of who each person must strive to become.

마지막으로, 역사는 지금과 같이 점점 더 전문화되어가는 시대에 의사가 된다는 것의 의미가 무엇인지 깨닫게 해준다.

Finally, history fosters appreciation of what it means to be a doctor first and foremost in an era of spiraling specialization. Osler used history, as Donald G. Bates23 put it,

 

as a source of inspiration, …

존경받고 명예로운 전문직에 대한 감각을 높여주고  to heighten [students’] sense of belonging to a venerable and honorable profession, …

전문직으로서의 단결심을 고취시켜준다 to the promotion of a professional esprit de corps, [to come] together as members of a fraternity.

activist professionalism을 향상시키기 위한 의사학 교육

Teaching medical history to promote activist professionalism

이제는 의료의 불평등이나 환자의 관점을 간과하는 것, 혹은 그것이 존재하지 않는 것을 무시할 수 없게 되었다. 오슬러 시대의 의사는 종종 더 나은 의료접근성을 위한 켐페인을 벌이곤 했다. 비록 그들이 아픈 환자들에게 해줄 수 있는 것이라곤 약간의 약과 약간의 수술과 곁에 있어주는 것 뿐이었지만 말이다.

It is no longer permissible for serious medical historians to ignore the sorry record of health care disparities or to overlook patients’ perspectives on their care or lack thereof. Physicians of Osler’s period seldom campaigned for better access to care. They had little to offer seriously ill patients other than a few drugs, a few operations, and their presence at the bedside. The physiologist Lawrence J. Henderson24 famously remarked:

Somewhere between 1910 and 1912 in this country [the United States], a random patient, with a random disease, consulting a doctor chosen at random had, for the first time in the history of mankind, a better than fifty­fifty chance of profiting from the encounter.

오슬러와 그 이전 세대에 가끔 등장하던 의사-운동가는 노예제에 반대하고, 공공보건을 증진시키고, 여성과 소수인종의 권익 향상을 주장하던 정치적 운동가political activism 로 기억되곤 한다. 오슬러 전기의 어떤 부분도 사회 운동으로서 잘 알려져 있지 않다.

The occasional physician–activists of Osler’s and previous eras are best remembered for political activism in such areas as opposition to slavery, promotion of public health, and the rights of women and racial minorities.25,26 Parenthetically, none of the subjects of Osler’s biographical sketches are well known for social activism.

건강보험과 제3지불인(Third ­party payers and health insurance)은 오슬러 시대에는 존재하지 않던 이슈였다. 그러나 오슬러가 의료의 과도한 상업주의와 기업화에 격렬히 반대했음에도 오늘날에는 매우 중요한 문제가 되었다. 오슬러는 학생에게 다음과 같이 말했다.

Third ­party payers and health insurance were never issues in Osler’s lifetime. Highly relevant today, however, is Osler’s vigorous opposition to excessive commercialism and entrepreneurialism in medicine. He told students,

 

일단 순전한 사업 영역으로 내려가면, 너의 영향력은 사라질 것이고, 당신의 삶을 비춰주는 진정한 빛도 희미해질 것이다.

“Once you get down to a purely business level, your influence is gone and the true light of your life is dimmed.”27

 

Progressive Era (1890~1920)의 많은 사람들이 그랬던 것처럼 오슬러가 지닌 미래에 대한 신념은 과학에 기반을 둔 것이었으며, 특히 의과학에 대한 것이었다. 만약 그가 살아있었다면 비용-효과적인, 근거-기반 의료에 대한 접근성 향상을 주장했을 것이다.

Like many people during the Progressive Era (roughly, between 1890 and 1920), Osler rooted his faith in the future of humankind largely in science, especially medical science, and even gave to this effect a lay sermon, “Man’s Redemption of Man.”28 Were he alive, Osler would almost certainly champion wider access to cost­effective, evidence­based health care.

의사학 교육 방법

Methods for Teaching the History of Medicine

X세대와 Y세대는 의사학과 위인전을 공부하는 것이 순진하고, 그저 과거를 미화하는 것이라 저항할 것이다. 오늘날의 의대생과 젊은 의사들은 왜 이것이 중요한지 알아야 한다. 의사학은, 심지어 nostalgic한 것이라도, 확실한 목적과 목표를 가지고 도입되어야 하나, 단, 흥미와 재미를 느끼게 교육해야 한다.

Members of Generations X and Y are likely to resist, as they should, medical history and biography as naïve, feel­ good nostalgia. Today’s medical students and young physicians desire and deserve to know why this or that subject matters. Medical history, even of the “nostalgic” kind, should be introduced with clear goals and objectives and taught in a relevant yet entertaining way.

공식 교육과정

The formal curriculum

1950년대와 1960년대에는 미국과 캐나다 의과대학에 의사학을 열광적으로 넣었다.

During the 1950s and 1960s, enthusiasm for medical history in the formal curriculum prompted surveys of U.S. and Canadian medical schools.30–33

소수의 의과대학이 의사학을 필수 과목으로 하고 있으나, 새로운 요건requirement를 넣는 것은, 대부분의 학교의 교육과정 위원회에게 잘 받아들여지지 않을 것이다.

A few medical schools have superb required courses in medical history, but proposing a new requirement would, in most schools, probably be a tough sell to the curriculum committees.

우리는 가장 효율적이고 효과적인 방법은 각 교실이 introductory lecture에 넣는 것이라고 제안한다.

We suggest that the most efficient and effective way to jump­ start a new history of medicine program would be to have each department include, during the introductory lectures,

비공식 멘토링

Informal mentoring

오슬러가 JHU에 있는 기간동안, 그는 의사학을 완전히 비공식 멘토링으로만 가르쳤다.

Osler’s 1913 Silliman lectures at Yale University34 remain among the best start­ to ­finish overviews of the evolution of Western medicine up to the turn of the 20th century. However, during his storied career at Johns Hopkins University (1889–1905), Osler taught the history of medicine almost entirely by informal mentoring. During weekly evening sessions with students at his home, he often introduced historical topics and passed around rare medical books from his collection.35 Osler’s protégé and biographer Harvey Cushing36 described

the Oslerian method of slowly but surely arousing an historical appetite by the proper touch in each exercise upon the historical bearings of the subject under discussion, whatever it might be,—an eponymic question asked, the original source­books passed around, a paragraph read, a picture shown or an incident related. In this way, by the process of repeated inoculations, many students who unquestionably would have sidestepped a formal course of lectures became unconsciously impregnated with something much more valuable to them in the long run than the requirement of just a few more facts concerning diagnosis and treatment.

윌리엄 오슬러는 언제나 긍정적이었으며, 이상주의, 연대, 행동주의 라는 이 반드시 필요한 것들desiderata의 정수를 한 문장으로 요약했다.

William Osler,37 ever the optimist, captured in one sentence the essence of these desiderata—idealism, solidarity, and activism—in a 1905 farewell address to the medical profession of the United States:

Linked together by the strong bonds of community of interests, the profession of medicine forms a remarkable world ­unit in the progressive evolution of which there is a fuller hope for humanity than in any other direction.

 

 

---

Acad Med. 2013 Jan;88(1):97-101. doi: 10.1097/ACM.0b013e31827653f5.

Perspective: Teaching and mentoring the history of medicine: an Oslerian perspective.

Bryan CS1, Longo LD.

Author information

• 1University of South Carolina School of Medicine, Columbia, South Carolina, USA. charles.bryan@providencehospitals

Abstract

Many predict a takeover (seen by some as hostile, and by others as inadvertent) of professional virtues and values by government and capitalism. One source of professional virtues and values consists of lessons from the history of medicine as taught and mentored by Sir William Osler. Some medical schools have required courses in medical history, but proposing a new requirement would probably be a tough sell to most curriculum committees. Osler himself argued against compulsory courses in medical history. The authors propose that exposing medical students to the historyof medicine promotes at least two of the seven types of professionalism identified by Hafferty and Castellani. Exposure to the evolution of medical science and to exemplary physicians of bygone eras promotes nostalgic professionalism, which, although in some ways suspect and naïve, fosters a sense of belonging and solidarity as members of a profession, not a trade, whereas exposure to the evolution of medicine as a public service, to the sad history of health care disparities, and to patients' perspectives promotes activist professionalism, fostering a sense of civic responsibility and opposition to excessive commercialism.Steps to promote such exposure include (1) identifying faculty, community physicians, and others interested in the history of medicine, (2) including the history of medicine in faculty development programs, (3) considering a segment in the historyof medicine during the introduction to each major course, (4) sponsoring history clubs, and (5) promoting environments favorable for mentor-protégé relationships for faculty and students with further interest.

PMID:

 

23165269

 

[PubMed - indexed for MEDLINE]