의학교육자 되기: 동기, 사회화, 항해 (BMC Med Educ, 2014)

의학교육자 되기: 동기, 사회화, 항해 (BMC Med Educ, 2014)

Becoming a medical educator: motivation, socialisation and navigation

Emma Bartle* and Jill Thistlethwaite

Background

의학교육인력이 부족함에 대한 우려

There is increasing concern about a medical education workforce shortage [1].

의사들은 언제나 교육에 헌신해왔다. 실제로 이것은 의-전문직업성의 요소로서 인정받고 있다. 이러한 책무성은 영국의 fundation curriculum과 호주의 curriculum framework에도 나타나있으며, 'teaching'을 모든 junior의사의 핵심 역량으로 보고 있다.

Doctors have always had a commitment to teaching; indeed this is a well recognised component of medical professionalism. This responsibility is further professio- nalised in both the foundation curriculum in the UK (‘demonstrates the knowledge, skills, attitudes and beha- viours to undertake a teaching role’ [2]) and the Australian curriculum framework for junior doctors (‘plans, develops and conducts teaching sessions for peers and juniors; uses varied approaches to teaching small and large groups; incorporates teaching into clinical work; evaluates and re- sponds to feedback on own teaching’ [3]), which include teaching as a core competence for all junior doctors, re- gardless of their career choices.

대학의학은 교육/연구/진료라는 세 가지 상호관련된 기둥 위에 세워져 있다.

Academic medicine is founded on the three pillars of clinical service, research and teaching, and the interrela- tionships between them [4].

연구와 교육과 관련된 academic career를 선택하는데의 장애요인으로 다음이 연구된 바 있다.

The deterrents to pursuing an academic career both in relation to research and teaching have been summarised, for example by Walport in the UK, [5] as

• 진입 경로 불분명 a lack of clear entry routes,

• 구조화된structured 진로 structured career pathways,

• (직장으로) 선택가능한 지역의 유연성 문제 flexibility in terms of the geography of available places,

• 진료와 학문 업무(와 생활)의 균형 balance of work between service and academia (and life), and

• 수련을 마칠 때까지의 적저한 구조와 재정지원 가능성 the availability of properly structured and funded posts on completion of training.

추가적으로, 임상교육자의 성공은 교육이 아니라 연구생산성과 진료을 기준으로 측정된다는 문제가 있다. Harmon이 지적한 바와 같이, '연구'는 전통적으로 대학에 기반을 둔 의료전문직만이 할 수 있는 독특한 기여unique contribution으로 인식되어 왔다. 또한 '의학교육자'의 정의에 대한 명확한 합의가 부족하다.

Additionally, as with academic careers in other sectors, the success of clinical educators is measured in terms of research pro- ductivity and clinical service rather than teaching. As Harmon notes, it is research that is traditionally perceived to be the unique contribution of university-based aca- demia to the medical profession and wider community [6]. We also note a lack of consensus as to the definition of a ‘medical educator’.

대학의학의 학문구조와 연구를 중시하는 문화가 연구보다는 교육을 선호하는 임상의사들의 inauthenticity와 marginalisation 감정을 유발한다는 것을 보여주는 연구

The study indicated that the discipline structure of academic medicine and the research-focused culture of academic and institutional expectations could engender feelings of inauthenticity and marginalisation for those clinicians who favour teaching over research.

연구의 Context

The context of this study 

호주 퀸스랜드. 지난 10년간 호주정부는 의과대학을 늘림으로써 의과대학생 수를 크게 늘렸고, 의대 졸업생 수도 늘어났다.

The setting for this study was Queensland, Australia. In the last decade the Australian government has signifi- cantly increased the number of medical students through the expansion of existing medical schools and funding of new schools. This has led to a marked rise in the number of medical graduates [8]

2007년, 퀸스랜드 보건부는 임상교육 및 훈련 영역의 역량 강화 필요성을 느껴서 2008년 Medical Education Registrar (MER) 프로그램을 만들었다. MWAC가 네 명의 MER에게 재정을 지원했다.

In 2007, Queensland Health (the funder and supplier of the state’s health service, with a network of 17 hospital and health service districts across Queensland) identified its own need to build capacity in the area of clinical education and training [10] and in 2008 developed the Medical Education Registrar (MER) scholarship pro- gram for this purpose (Table 1). Medical Workforce Advice and Coordination (MWAC) provided funding for four fulltime hospital-based MER positions per year across Queensland from 2008–2012.

12개월 프로그램

The MER positions were designed as a 12-month period of developmental experience for junior doctors, within the context of the registrar (resident) career continuum.

 

Table 1 The objectives of the MER position [11]

 

이론적 프레임워크

Theoretical framework

사회-인지-경력이론(socio-cognitive career theory , SCCT)를 따라서 데이터 분석

As discussed further below we adopted socio-cognitive career theory (SCCT) as a framework for the data analysis as we read through the transcripts.

Bandura의 사회-인지 이론으로부터 나온 SCCT는 개인의 진로흥미/진로선택/수행능력의 상호작용과 어떻게 개인요인(기대성과, 자기효능감, 목표)이 장애요인에 대한 맥락적/경험적 지지와 관계되는지 이해하도록 도와줌. SCCT에서는 뛰어난 수행능력을 갖추기 위해서는 개개인이 component skill과 강력한 자기효능감이 필요하다고 가정함.

Derived primarily from Bandura’s general social cognitive theory [13], SCCT provides a useful conceptual framework for understanding the interplay between an individual’s career interests, choice and performance, as well as understanding how personal factors, such as out- come expectations, self-efficacy beliefs and personal goals, can interrelate with contextual and experiential supports or barriers [12]. SCCT assumes that individuals require both component skills and a strong sense of self-efficacy to achieve competent performance [14].

자기효능감은 특정 역할을 수행하는 능력에 대산 스스로의 판단, 구체적인 상황에서 성공에 대한 판단 등이며 타인/관찰학습/행동/맥락요인에 영향을 받는다.

Self-efficacy is used to describe people’s self-judgements of their capability to perform a role and succeed in specific situations, and can be influenced by other people, observa- tional learning, behaviour and contextual factors [13,15].

자기효능감에 대한 신념은 활동의 선택/노력과 끈기/사고 패턴/감정적 대응에 영향을 미친다. 자기효능감은 학업과 진로 관련 선택 및 그 수행능력의 예측인자.

In particular, self-efficacy beliefs are thought to impact on an individual’s activity choice, effort and persistence, thought patterns, and emotional reactions [12]. Self-effi-cacy has been found to be predictive of academic andcareer-related choice and performance [16-18].

기대성과outcome expectation은 개개인이 주어진 맥락에서 구체적인 행동이 어떤 결과를 가져올 것인가에 대한 추측이다. 개인목표는 한 사람이 자신의 행동을 조직화하고 행동을 guide하기 위해서 설정한 개인적/전문직적/생활적 목표이다.

Outcome expectations refers to an individual’s estimate that a specific behaviour within a given context will lead tocertain outcomes [12,13]. Personal goals describe the per-sonal, professional and lifestyle goals set by individuals to organise their behaviour and guide their actions

진로 장애요인이란 희망 진로에 불협화음을 내는 개인적/맥락적 요인 등이며, 기대성과에 부정적 영향을 준다.

notion of career barriers, personal and contextual factors which result in dissonance among career aspirations, progress and achievement. Overall, car-eer barriers engender negative outcome expectations in those contemplating a particular career pathway [19]. 

 

임상연구 진로 개발에는 여러 어려움이 있다.

[20]. They found that the development of a clinical re- search pathway has many potential challenges, including

• low self-efficacy beliefs,

• over commitment,

• negative out- come expectations,

• ill-defined personal goals, and

• the conflicting demands and expectations of the multiple environments an individual may inhabit.

방법

Methods

 

자료 수집 

Data collection

1회 혹은 2회 

Interviews with participants were conducted at either one or both of two time-points:

인터뷰어 사이의 일관성 유지 

We developed an interview question guide, ensuring that a level of consistency in the broad topics covered was maintained across the three interviewers (the two authors and a research assistant).

자료 분석

Data analysis

프레임워크분석: 이미 정의된 연구질문에 기반하여 귀납적으로 접근함 

The interviews were transcribed verbatim and firstly analysed by the two authors and the research assistant using framework analysis [23], a deductive approach based on our defined research questions and the medical education workforce issues prompting the study.

주제 사이의 관련성, SCCT와의 비교, 결과의 해석 등을 논의하여 presented text를 최종 결정. RATS 가이드라인 따름.

The association between themes, compari- son with SCCT and interpretation of the findings were discussed by authors both to finalise the text presented. Our study adheres to the RATS guidelines for reporting qualitative studies.

결과

Results

 

 

진로 선택의 동기: 더 나은 교육을 위한 열망wanting

Motivation for career choice: wanting to provide better education

 

자신의 부정적인 경험이 (자신을 가르친 사람보다) 더 나은 방식으로 가르칠 수 있겠다는 관심을 갖게 해줌

Their negative experi- ences in particular motivated their interest in being able to teach better than their own teachers.

 

senior의사로서 교육이 기본 역할이라는 것을 알게 되면서, 교육스킬은 nurture가 필요한 것이며, natural하게 얻어지는 것이 아니라는 것을 알게 됨.

while identifying that teaching is a fundamental role of the senior clinician, they highlighted that it is a skill that needs nurturing ra- ther than something that would come naturally to a doctor:

Table 2 Themes arising from the data

 

개인의 목표, 기대, 자기주도성의 필요성

Personal goals, expectations and the need for self-direction

 

MER들은 커리어 목표가 있고, 더 나은 교육자가 되려는 동기부여 요인이 있었지만, 그 외에 이 프로그램에서 무엇을 기대했는지 고려하지 않았음.

While the MERs had career goals and the aim of deve- loping as better educators as motivating factors to undertake the MER position, many had not considered what they otherwise hoped to achieve during the post itself.

이러한 목표설정의 부재, 잘 정의되지 않은 목표는 이 프로그램을 시작할 때 방향설정orientation이 부족한 것, 그리고 이 포지션에 있으면서 무엇이 가능하고 허용되는지를 결정하는 것에 대한 자기주도성이 필요했던 것과 관련됨.

This lack of goal setting, or ill-defined goals, was partly related to the lack of orien- tation at the start of the post and partly due to the need for self-direction in determining just what was possible and permissible during the position itself:

그러나 자기주도성(이 요구되었던 것)을 후향적으로 성찰해볼 때 장점도 있음. 

However in retrospect this self-direction was seen as an advantage:

동료와 선배 의사들이 이 역할이 무엇인지 잘 이해하지 못함.

The lack of understanding of the role by their peers and more senior clinicians could be frustrating:

'일부 병원에서는 의학교육을 행정으로 보기도 하며, 어떤 전공의들은 명백히 자신의 역할이 아닌 행정업무를 하고 있었다.'

‘Some hospitals also interpreted medical education as medical admin and so we found that some registrars were doing administration which is not part of it obviously.’ (12b) 

임상 로테이션 중의 과도한 업무와 MER에서 요구되었던 자기주도성은 transition 기간을 더 어렵게 만들었는데, 시간이 너무 많아서, 혹은 그 포지션에서 맡은 역할들에게 요구되는 행동의 균형을 맞추기 위해서가 그 이유였다.

The contrast between the heavy workload of a clinical rotation and the self-direction required as a MER made for a difficult period of transition, either because of the luxury of time or the balancing act required for the number of roles within the position:

 

롤모델의 영향

The influence of role models

롤모델은 여러가지 위장된 형태로 존재한다.

Role models took many guises: 

'그들은 심지어 약 절반의 시간 동안 가르치고 있다는 것도 모른다. 그들에게는 이것이 너무 자연스럽고, 그들은 소수만 이해하는esoteric 것을 가르치는 것이 아니다. 내가 멘토/롤모델로서 생각하는 이 사람들은 중요한 것을 가르쳐 주었다.'

‘The fact that they don't even know they're teaching half the time, it comes so naturally to them and they're not teaching esoteric stuff. That's my point of view is that these people that I view as mentors or role models have taught me the important stuff.’ (4a)

롤모델을 찾은 다음, 초심자들은 이들 롤 모델의 특성과 행동에 비추어 성찰을 하고 발전한다.

Having identified their role models, novices need to reflect on those role models’ attributes and behaviour in order to improve:

정체성 찾기

Defining one’s identity

MER은 교육자로서의 신뢰성과 환자진료에 대한 헌신 모두에 대해서 임상적 정체성을 유지하는 것이 중요함을 강조했다.

The MERs emphasised the importance of continuing with their clinical identity in terms of credibility as an educa- tor and their commitment to patient care:

일부 응답자는 스스로를 다양한 정체성이 있다고 했으며, 그러나 다른 사람들은 의료계medical community에서 자신의 포지션에 대한 보다 고정된 생각을 갖는다고 했다.

Some respondents’ role saw themselves as having mul- tiple identities whereas others had much firmer ideas of their position in the medical community.

연구(자)는 보다 덜 중요한 정체성이었다. 

Research as a component of the role or their identity was much less important:

지지: 관리자supervisor와 멘토 

Supports: supervisors and mentors

지지support와 전문직적 가이드professional guidance 가 MERS에서 가장 중요한 특정이었는데, 종종 이것은 두 명의 관리자가 존재하는 것 때문에 복잡해지기도 했다. 한 사람은 의학교육분야의 관리자이고, 다른 사람은 전공과의 관리자이다.

In terms of support and professional guidance the super- visor was the most important figure for the MERS, though this was somewhat complicated by having two supervisors during the term: the one responsible for the medical education part of the role (and their experience varied) and the other the discipline supervisor:

교육에 대한 지식이 충분하지 않은 관리자를 두는 것은 힘든 일이었으며, 프로젝트에 대한 기대에 관련된 문제였다.

Not having a supervisor with sufficient knowledge of education was difficult and this was particularly an issue in relation to the expectation of doing the project:

'내가 가장 힘들었던 것은 mentorship 문제였다'

 ‘Probably part of the reason that it was so frustrating…was the mentorship.

교육을 계속 하는데의 장애요인: 연구

Potential barriers to pursuing education: the need for research

의학교육연구에 대한 열정은 많지 않았다. 연구 능력과 연구결과의 발표delivery는 academic career에서 기본적 요건이었고, 따라서 연구에 흥미가 없는 것은 academia에 남는 장애요인이었지만, 임상교육자로서의 역할에 대해서는 그렇지 않았다.

There was not much enthusiasm for pursuing medical education research. Research capability and delivery were seen as fundamental requirements for an academic career, and therefore the lack of interest in research was a barrier to academia but not necessarily to the clinician educator role.

의과대학에서 연구논문을 읽고 해석하는 과목이 있었지만 연구에 참여할 기회는 별로 없었다.

Even though there had been courses on reading and interpreting research papers during medical school, there had been little exposure or opportunity to get involved in research prior to the MER role:

evaluation을 수행할 자신감 혹은 능력의 부족

There was also lack of capability or confidence to undertake evaluation:

고찰

Discussion

Despite their initial beliefs that they could perform better than their own teachers, as participants navigated the role there was gradual recognition that teaching is a skill that needs to be nurtured and developed and does not necessarily come naturally.

시니어 의학교육자로부터 교육 스킬을 배울 공식적 기회의 필요성. 임상에서 조금 멀어져 시간이 필요하나 이것이 부정적 영향을 줄 수도. 동료로부터 인정을 받아야 함. 주변에서 MER역할에 대해 명확한 이해가 부족했고, 이것이 주니어 의사가 교육자로서 professional socialisation 되는데 부정적 영향 가능성 있음.

Recent studies on the developmental needs of junior doctors entering academic medicine have identified the provision of role models and creation of research opportunities as key requirements [21,22,25,26], yet there has been little discussion on the need to develop teaching skills. Our findings testify to the need to provide formal opportunities for junior doctors to learn these from senior medical educators, to facilitate their development as medical educators. This could require time away from clinical work, something that could negatively impact a MERs motivation to participate in this type of activity. It would also require recognition by colleagues of the credibility of an education career pathway; our findings illustrate there was no clear understanding of the MER roles by others in the system and they can be seen as a soft option. The failure of colleagues to recognise the MER positions as credible, negatively impacted on the junior doctors’ professional socialisation as educators.

정체성 측면에서 '전문의로서 일하면서 교육에 흥미가 있고 스킬을 갖춘 의사'로 인정받고자 했고, 임상의에 대한 정체성이 첫 번째임, 교육자로서의 정체성은 두 번째였다. 동료로부터 인정을 받지 못하기도 했음. 개인적 요인과 맥락적 요인의 misalignment가 있을 때 부정적 결과가 나올 수도 있음.

The sense of identity emerged as a strong theme from the data. The MERs were not motivated by the chance to develop an academic career but wished to be seen as doctors with an interest and skill in education while working as specialists. These junior doctors primarily described themselves as clinicians; the identity of educator was seen as secondary to their main role. A consistent concern about the primacy of clinical work was expressed, and some respondents felt a strong pull back to full time clinical practice. When discussing identity, the role of an educator in a clinical environment, though often described as complementary, was almost always implicitly viewed as secondary to that of clinician. The lack of acknowledgement by peers of the validity of the role contributed to a dissonance between career aspirations and achievement. Misalignment between personal and contextual factors such as these have been reported to engender negative outcome expectations for those considering a specific career pathway [19,27].

병원에 따라 각자의 필요성에 맞춰 MER 포지션의 목적이 달라졌다. 이것이 일부 참여자에게는 힘든 일이었으나, 일부 자기-동기부여가 잘 되고 자신의 시간을 어떻게 사용할지 아는 참여자에게는 유용하기도 했음. 오리엔테이션이 도움이 될 것.

The purpose of the MER position in different hospitals varied between sites based on hospitals’ needs, while also being capable of being tailored quite closely to the motivations of each MER. This different experience of structure and autonomy than in clinical roles was challenging for some participants as they navigated the role. However the lack of a formal position description was useful for those who were self-motivated and able to decide how they wanted to pursue their time. Certainly orientation would have been helpful and particularly a chance to talk to others in the role of those who have had the role previously.

연구가 가장 큰 장애요인이었고, 연구에 대해서는 별 열정이 없었음. 실제 연구경험도 적었고, 어떻게 교육적 인터벤션을 평가할지에 대한 아이디어가 부족햇음. 그들은 자신의 병원에서 임상교육을 개선시키고 싶었으며, 교육에 관심이 있는 전문의가 되고 싶어했음. 또한 병원에 지원할 때hospital posts 다른 사람보다 걸출한 모습을 보여주고 싶었음. 이러한 결과는 "임상교육자의 등장을 더 촉진시키기 위해서는, 현재 연구를 중심으로 임상의사들을 의학교육분야로 사회화socialize시키는 방식이 변화할 필요가 있따"라는 Kumar 등의 권고와 부합함.

The need for research was the biggest barrier to participants when considering whether to continue on a medical education career pathway upon completion of the post. There was not much enthusiasm for pursuing medical education research. Unlike the findings of O’Sullivan et al. whose respondents spoke of early exposure to research opportunities, our participants had little practical research experience other than an introduction to critical appraisal at medical school. This meant they had limited ideas of how to evaluate educational interventions or indeed gauge the success of their own projects. Teaching, hands-on and development, was the main objective and there was no particular interest in research or academia. They want to enhance clinical teaching in the hospitals and become specialists with an interest in education. This interest may also be of use for them to stand out from others applying for hospital posts. These findings support the recommendations of Kumar et al.[7], who in a recent study of clinician educators at the University of Sydney concluded that to facilitate the rise of the clinician educator, the current focus on socialising clinicians into medical education in terms of research will need to change substantially.

 

 

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BMC Med Educ. 2014 May 31;14:110. doi: 10.1186/1472-6920-14-110.

Becoming a medical educator: motivation, socialisation and navigation.

Bartle E1, Thistlethwaite J.

Author information

• 1Centre for Medical Education Research and Scholarship, School of Medicine, The University of Queensland, 288 Herston Road, Herston, QLD 4006, Australia. e.bartle@uq.edu.au.

Abstract

BACKGROUND:

Despite an increasing concern about a future shortage of medical educators, little published research exists on career choices inmedical education nor the impact of specific training posts in medical education (e.g. academic registrar/resident positions). Medical educators at all levels, from both medical and non-medical backgrounds, are crucial for the training of medical students, junior doctors and in continuing professional development. We explored the motivations and experiences of junior doctors considering an education career and undertaking a medical education registrar (MER) post.

METHODS:

Data were collected through semi-structured interviews with junior doctors and clinicians across Queensland Health. Framework analysis was used to identify themes in the data, based on our defined research questions and the medical education workforce issues prompting the study. We applied socio-cognitive career theory to guide our analysis and to explore the experience of junior doctors in medical education registrar posts as they enter, navigate and fulfil the role.

RESULTS:

We identified six key themes in the data: motivation for career choice and wanting to provide better education; personal goals, expectations and the need for self-direction; the influence of role models; defining one's identity; support networks and the need for research as a potential barrier to pursuing a career in/with education. We also identified the similarities and differences between the MERs' experiences to develop a composite of an MER's journey through career choice, experience in role and outcomes.

CONCLUSIONS:

There is growing interest from junior doctors in pursuing education pathways in a clinical environment. They want to enhance clinical teaching in the hospitals and become specialists with an interest in education, and have no particular interest in research or academia. This has implications for the recruitment and training of the next generation of clinical educators.

PMID:

 

24885740

 

[PubMed - indexed for MEDLINE] 

PMCID:

 

PMC4047547

 

Free PMC Article