Mareiniss Darren P
New York University School of Medicine, New York, NY, USA.
Acad Med. 2004 Sep;79(9):825-31. doi: 10.1097/00001888-200409000-00003.
The author evaluates current concerns over medical professionalism in residency training. The recent professionalism requirements for residents promulgated by the Accreditation Council for Graduate Medical Education (ACGME) are discussed in relation to the atmosphere of current training. The author first reviews a recent study showing that unprofessional behavior may significantly correlate with burnout, as evaluated by the Maslach Burnout Inventory. Among the elements of that inventory, depersonalization is shown to significantly correspond to unprofessional actions and behavior. Several surveys and studies evaluating residency treatment and stress are reviewed and three sources of training stress are identified: (1) abusive treatment of residents, (2) financial pressures, and (3) pessimism and uncertainty in the medical field. The extent and effects of these stressors are discussed and evaluated in relation to depersonalization, depression, and unprofessional behavior. Each of these pressures is found to correlate with negative effects on residents, such as depersonalization, decreased satisfaction, depression, and burnout. In turn, such effects are found to potentially cause unprofessional behavior among residents. In light of these findings, the author suggests several modifications to the current graduate medical training environment to mitigate such stressors, promote professionalism, and increase morale. Prevention of abusive treatment of residents, alleviation of financial pressure, increased educational opportunities, and role modeling are suggested as beneficial interventions that may foster professionalism and prevent inappropriate behavior. The author indicates that such environmental changes would likely foster professionalism in young physicians more effectively than would ethics seminars or in-class training. Accordingly, the author suggests environmental changes to decrease residency stress as the most effective means of promoting the new ACGME requirements and the ideals of professionalism.
作者评估了当前住院医师培训中对医学职业精神的关注。结合当前培训的氛围，讨论了研究生医学教育认证委员会（ACGME）最近颁布的住院医师职业精神要求。作者首先回顾了一项近期研究，该研究表明，根据马氏职业倦怠量表评估，不专业行为可能与职业倦怠显著相关。在该量表的各项要素中，去人格化被证明与不专业行为显著相关。回顾了几项评估住院医师待遇和压力的调查与研究，并确定了培训压力的三个来源：（1）对住院医师的虐待性对待；（2）经济压力；（3）医学领域的悲观情绪和不确定性。讨论并评估了这些压力源的程度和影响与去人格化、抑郁和不专业行为的关系。发现这些压力中的每一种都与对住院医师的负面影响相关，如去人格化、满意度下降、抑郁和职业倦怠。反过来，则发现这些影响可能导致住院医师出现不专业行为。鉴于这些发现，作者建议对当前的研究生医学培训环境进行若干改进，以减轻此类压力源、促进职业精神并提高士气。建议防止对住院医师的虐待性对待减轻经济压力、增加教育机会和树立榜样，作为可能促进职业精神和防止不当行为的有益干预措施。作者指出，此类环境变化可能比伦理研讨会或课堂培训更有效地培养年轻医生的职业精神。因此，作者建议通过环境变化来减轻住院医师压力，作为促进新的ACGME要求和职业精神理想的最有效手段。
