의학교육의 이론적 측면: 과거의 경험, 미래의 가능성 (Medical Education, 2011)

의학교육의 이론적 측면: 과거의 경험, 미래의 가능성 (Medical Education, 2011)

Theoretical perspectives in medical education: past experience and future possibilities

Karen V Mann

우리가 '학습'에 대해 가지고 있는 관점이 교육에 대한 접근법을 바꾼다.

We have perspectives on learning which determine the choices we make among pedagogic approaches in medical education.

'앎'에 대한 관점 변화 Changes in our ways of knowing

플렉스너 이후에 가장 큰 변화는 '구성주의'의 등장이다. 구성주의자는 외부의 객관적 사실에 초점을 두는 것이 아니라, 그것이 학습자에 의해서 어떻게 구성되느냐에 관심을 갖는다. 이러한 관점에서 학습자는 이전의 경험, 인식, 지식을 바탕으로 지식을 능동적으로 구성하는 사람이다.

One of the most important shifts since Flexner relates to the emergence of constructivism. In the constructivist view, the focus is not on an objective external reality, but, rather, on how it is constructed by the knower. This perspective views the learner as an active constructor of knowledge based on previous experience, perceptions and knowledge.

의학교육 담론의 변화 Changes in the discourse of medical education

의학교육 담론 역시 큰 변화가 있었는데, '학습'과 '학습자'의 측면에서 학습자는 능동적으로 지식을 구성해나가는 사람이며, '촉진적 학습'의 측면에서 학습자에 좀더 중심을 두고 교수자-학습자 관계를 강조하게 되었다. 마지막으로 교육과정과 조직 차원에서 '학습자 중심'의 교육이 강조되었다.

There have been changes in the discourse of medical education that suggest major philosophical and theoretical shifts. Describing the processes associated with learners and learning conveys that learners are not passive recipients of information; rather, they are active knowledge builders. Speaking of facilitating learning as an important purpose of teaching shifts the balance of agency towards the learner and highlights the teacher– learner relationship. Lastly, at the curricular and institutional levels, espousing activities and curricula that are learner-centred implies that education is driven by learner needs.

의학교육에 대한 관점의 변화 Changes in our view of medical education

의학교육의 근본적 차원에서 효과적인 학습은 무엇이며, 의사에게 필요한 전문직으로서의 특성은 무엇인지에 대한 변화가 있었다. 첫 번째로, 교육자들에게 오늘날의 의학교육은 '지식/기술/태도'를 습득하는 것 이상이며, 그 본질은 '전문직으로서의 정체성'을 구성해나가는 과정이다. '보통 사람'으로 입학하여 '전문직'으로 변모해가는 과정이며, 주로 학부 의학교육과 졸업 후 수련과정에서 크게 변화하지만 거기서 멈추는 것은 아니다. 이는 평생에 걸친 과정이다.

Significant changes have occurred in our understanding of the fundamental aspects of medical education, of what constitutes effective learning and of the professional attributes required of doctors. Firstly, to educators, medical education today is understood as more than the acquisition of knowledge, skills and attitudes; it is, at heart, the construction of a professional identity, the transformation of the entering individual from lay person to professional, a transformation which may be more intense at the level of undergraduate and postgraduate medical education, but which does not stop there. Transformation and learning are lifelong.

두 번째로 '생각할 수 있는', '의사결정을 내리고', '문제를 규정하고 해결하는' 것이 학습이라고 했을 때 배운 그대로의 지식을 그대로 적용하는 것이 아니라, 배운 지식을 통합하고 융화시키는 것이 강조되었다. 전문가는 새로운 문제에 대해서 새로운 해답을 찾을 수 있어야 하며, 학습의 효과적 통합을 해내는 습관이 필요하다.

Secondly, an understanding that learning to think, make decisions and frame and solve problems involves the integration and assimilation of developing knowledge, rather than a straightforward application of theoretical knowledge to the problems encountered, has also developed.7 Expertise involves the capacity to develop new solutions for new problems.8 Habits of mind that enable effective integration of learning are required.

마지막으로, 전문직으로서 지녀야 할 특성이 크게 진화하였으며, 이는 의학교육의 목표와 기대를 변화시켰다. 그리고 그 결과 학습자들에게 '무엇을 배워야 하는가' 외에도 '어떻게 배워야 하는가'에 관한 역량을 증진시키는 것에 관심을 가지게 되었다.

Thirdly, and perhaps most importantly, the desired attributes of the professional have evolved significantly, bringing concomitant change in the goals and expectations of the medical education enterprise.

Acceptance of these goals has focused our gaze on helping learners develop competency in ‘how to learn’, as well as in ‘what to learn’.

이론적 관점 THEORETICAL PERSPECTIVES TO DATE

다음과 같은 것들이 있다.

Several important theoretical perspectives have influenced the pedagogy of medical education significantly over its history. These have been broadly characterised by their general orientation as behaviourist, cognitivist, humanist, social and constructivist theories of learning.13 Perhaps best known are the behaviourist theories, which view the environment as the major influence on learning and behaviour. 

긍정적/부정적 강화를 통해서 행동을 변화시키는 것은 의학교육에서 흔한 일이었으며, 당연하게 여겨졌었다.

Shaping behaviour through reward and both positive and negative reinforcement is common practice in medical education and has become part of its taken-for-granted culture.

인지심리학은 의학교육의 이론적 토대에 큰 기여를 하였는데, 어떻게 지식이 조직되고 저장되는지, 기억이 어떤 기능을 하는지, 어떻게 경험에서 의미를 이끌어내는지를 설명해주었다. 인지심리학은 전문성의 개발/임상추론/의사결정에 관해서도 많은 기여를 하였다. PBL의 이론적 토대는 인지심리학이라고 할 수 있다.

Cognitive psychology has contributed significantly to the theoretical underpinnings of medical education. It has explained processes such as how knowledge is organised and stored, how memory functions, and how individuals make meaning of their experience.13 Cognitive psychology has also illuminated the development of expertise8 and the processes of clinical reasoning16 and decision making.17 The theoretical foundations of problem-based learning (PBL) curricula are congruent with the cognitive orientation.18

인본주의적 관점은 학습을 '자기실현'의 수단으로 보는 것이며, 지속적인 자기개발을 통해서 개개인이 최고의 기능에 도달하는 수단인 것이다. 이러한 관점에서 자기규제와 자기주도펴생학습이 등장하였다.

The humanist orientation views learning as a means to self-actualisation and ongoing personal development so that individuals may achieve their maximal level of function. Within this orientation are theories of motivation,19 self-regulation and self-directed lifelong learning.20

자기주도성과 자기규제라는 관점이 가지고 있는 문제는 그것의 의미에 대해서 공통된 이해가 부족하여 이것을 교육적으로 도입하고 평가하는데 해소하기 어려운 큰 차이가 생긴다는 것이다.

Their importance notwithstanding, self-direction and self-regulation remain problematic concepts. The lack of shared understanding of meanings and wide variances in the implementation and evaluation of educational approaches have been difficult to resolve.21

사회인지이론은, 행동주의적, 인지주의적, 인본주의적 관점을 모두 포함하는 것이며, 학습자는 학습의 능동적 주체이며 학습자의 목표/태도/가치/지식/경험에 따라서 학습이 영향을 받는다. 학습자들은 'agency'를 가지고 있으며, 목표를 설정하고 목표에 따라 발전정도를 살필 수 있다.

Social cognitive theory (SCT),23 within the social learning theory orientation, incorporates the behavioural, cognitivist and humanist perspectives. It views the learner as an active agent in learning, and considers learning as influenced by the learner’s goals, attitudes, values, knowledge and experience. Learners are seen to have agency24 and as able to set goals and monitor their progress towards them

관찰을 통한 학습은 SCT의 근본이며, 의학교육에서 롤모델의 영향력을 강조한다.

Learning through observation is fundamental to SCT, which illuminates the influence of role models in medical education.25

이러한 다야한 이론들은 학습의 초점을 개개인의 활동 중 어디에 두느냐에 따라 특징지어진다.

The theories described above are characterised by their focus on learning as an individual activity.

이러한 이론적 관점들이 왜 의학교육에서 우세하게 되었는가를 살펴보는 것은 흥미로운 작업이다. 이론과 그 이론이 교육과정에 어떻게 활용되는지가 '가치'를 반영한다. 개개인의 학습을 강조하는 이론은 '의학'의 가치와 상통하며, 전통적으로 의사를 자주적이고 독립적으로 보는 관점이기도 하다. 더 나아가 이들 이론은 기존의 구조를 강화시키는 경향이 있는데, 이는 의학이 주도권을 쥐고 있는 직업군간 상대적 파워이기도 하다. 또한 의학교육의 담화가 변화하였으나 현장은 잘 변하지 않는다. 교육현장은 교수-학습의 '실질적 이론'을 반영한다. 

It is interesting to consider why these theoretical perspectives have been dominant in medical education. Theories, and their enactment in medical curricula, also reflect values. Theories that emphasise individual learning are congruent with the values of medicine, which has traditionally viewed the doctor as autonomous and self-reliant. Moreover, as Bleakley6 notes, these theories tend to reinforce existing structures, including the relative power of each of the professions, among which medicine has long been dominant. In addition, although the discourse of medical education has changed, it seems that practice is more resistant to change. Teaching practice reflects practical theories of teaching and learning.26

SHIFTS IN PERSPECTIVE: SOME FUTURE POSSIBILITIES

Carnegie Foundation for Teaching and Learning에서는 다음의 네 가지 권고안을 제시하였다.

One such impetus may be the publication of the Carnegie Foundation for Teaching and Learning’s call for reform of medical education.7 Four major recommendations for the reform of medical education are proposed:

• 1 teaching and learning to promote integration;
• 2 promoting habits of inquiry and improvement;
• 3 individualising learning, yet standardising assessments, and
• 4 supporting the progressive development of professional identity.

학습에 관한 비유가 새로운 관점을 만드는데 도움이 될 수 있다. Sfard는 '습득'과 '참여'라는 두 가지 은유를 제시하였다. '습득'에서 학습은 지식/태도/가치/역량을 습득하는 과정이다. '습득'이라는 관점에서 학습은 각 개인이 밟아나가는 과정으로, Sfard는 이러한 개념이 우리의 머리속에 너무도 깊이 박혀있어서 다른 은유가 나타나기 전까지는 우리가 그렇게 생각하고있다는 사실조차 인지하지 못한다고 말한다. 두 번째 은유는 '참여'이며, '참여'에서 학습은 무언가를 얻거나 성취하는 것이 아니라 끊임없이 무엇인가에 '참여'하는 것 자체가 학습이다. '습득'적 관점에서 지식은 상황을 막론하여 다양하게 통용될 수 있는 것이지만, '참여'적 관점에서 학습이란 학습이 일어나는 맥락(환경)과 불가분의 관계에 있으며, 그 환경에서 진행되는 사회적 관계에 박혀있는 것이다.

Metaphors for learning may be helpful in reframing. Sfard29 describes two metaphors: ‘acquisition’ and ‘participation’. In the ‘acquisition’ metaphor, learning is seen as the acquisition of knowledge, skills, attributes, values and competencies, in the sense that one acquires ‘goods’. Acquisition reinforces learning as an individual process. As Sfard notes, this metaphor is so deeply embedded in our thinking that we scarcely noticed it until other metaphors began to emerge. The second metaphor is that of ‘participation’. It views learning not as something to be acquired or achieved. Instead, participation is learning and, as participation is ongoing, learning is viewed as a continuous process. Whereas acquisition implies that knowledge can be transferred across situations, participation sees learning as inextricably tied to its context and embedded in the social processes there.

Situated learning and communities of practice

Situated learning belongs to those socio-cultural learning perspectives that assert that learning is always inextricably tied to its context and to the social relations and practices there; it is a transformative process that occurs through participation in the activities of a community.

They describe the role of the newcomer to the community as one of ‘legitimate peripheral participation’. In this process, newcomers or novices begin at the periphery of a community by observing and performing basic tasks. As they become more skilled, they move more centrally in the community.

The profession of medicine is a culture into which medical learners are being socialised as they learn. This socialisation is a transformative process, that of lay person to professional, and is a transformation that continues to evolve through the individual’s life.

Situated learning extends understanding of the clinical education process beyond the traditional view of apprenticeship,11 which focused on observation and imitation as the means through which learners acquired the knowledge and skills of the profession.

Lave and Wenger37 also helpfully distinguish between a teaching curriculum and a learning curriculum. A learning curriculum consists of situated opportunities for development, whereby the community becomes the learning resource and learning occurs in many ways. A teaching curriculum, by contrast, is constructed for the instruction of newcomers and thereby structures, and may limit, opportunities for learning and what is recognised as learning.

Professional identity development is both a personal and social process and is not separable from the knowledge and skills that are acquired. It emerges through participating in the ‘talk of the community’, and through both learning to talk and learning from talk.39

Social cognitive theory

Situated learning emphasises collective learning in communities; however, as Sfard29 notes, individual learners must acquire the knowledge and skills required.

In SCT, the individual learner brings his or her personal knowledge, skills, attributes and previous experience, and learns and interacts dynamically with all others in the setting, including teachers, patients, peers and colleagues, and with other contextual influences.

Workplace-based learning theories

Workplace-based learning theories broaden understanding of how and where learning occurs. They illuminate the workplace as a community of practice. Theories and models of learning at work also include constructs of participation and learning at both individual and collective levels. Billett30,31 describes learning and participation as inseparable. He sees learning at work as a co-construction, arising from the interactions between the learning opportunities afforded by the workplace and how individuals actively choose to engage with those opportunities.

Eraut’s32,33 model of learning at work also includes both social and individual aspects. He describes informal learning at work that occurs through experience and interaction with colleagues. Eraut32 also describes implicit or tacit learning which may occur in the absence of overt teaching and in which the individual has no awareness of having learned. He describes tacit knowledge as knowledge of contexts and organisations, acquired through a process of socialisation, observation, induction and participation.

Eraut’s concept of tacit knowledge and tacit learning has particular salience for medical education. It may occur when learners observe or encounter situations that challenge their values.

Informal learning may also occur through the ‘hidden curriculum’, a set of influences that operate systemically at the level of the institution and communicate the institution’s values. Learning in the hidden curriculum is complex and may both support and undermine the intended curriculum.45

Experiential learning and reflective practice

The notion of learning through experience46 has been widely accepted in medical education. Experiential learning, as described by Boud et al.,34 involves reflection on experience with the goal of transforming experience into learning. Experiential learning emphasises individual learning; reflection is intended to deepen understanding and to explore the broader context of experience.

Reflective learning and reflective practice are integral to all learning perspectives. Reflection allows learning to be actively assimilated.47 Reflection and reflective practice48 are themselves complex concepts.

IMPLICATIONS FOR TEACHING AND LEARNING

How might teaching and learning look different when viewed from these perspectives? Potentially, three facets of increasing the social dimensions of learning can be seen, involving approaches that maximise participation, that maximise learning from others and that build on natural community processes to ensure both individual and collective learning.

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Med Educ. 2011 Jan;45(1):60-8. doi: 10.1111/j.1365-2923.2010.03757.x.

Theoretical perspectives in medical education: past experience and future possibilities.

Mann KV1.

Author information

• 1Division of Medical Education, Faculty of Medicine, Dalhousie University, Halifax, Nova Scotia, Canada. karen.mann@dal.ca

Abstract

CONTEXT:

Pedagogical practices reflect theoretical perspectives and beliefs that people hold about learning. Perspectives on learning are important because they influence almost all decisions about curriculum, teaching and assessment. Since Flexner's 1910 report on medical education, significant changes in perspective have been evident. Yet calls for major reform of medical education may require a broader conceptualisation of the educational process.

PAST AND CURRENT PERSPECTIVES:

Medical education has emerged as a complex transformative process of socialisation into the culture and profession of medicine. Theory and research, in medical education and other fields, have contributed important understanding. Learning theories arising from behaviourist, cognitivist, humanist and social learning traditions have guided improvements in curriculum design and instruction, understanding of memory, expertise and clinical decision making, and self-directed learning approaches. Although these remain useful, additionalperspectives which recognise the complexity of education that effectively fosters the development of knowledge, skills and professional identity are needed.

FUTURE PERSPECTIVES:

Socio-cultural learning theories, particularly situated learning, and communities of practice offer a useful theoreticalperspective. They view learning as intimately tied to context and occurring through participation and active engagement in the activities of the community. Legitimate peripheral participation describes learners' entry into the community. As learners gain skill, they assume more responsibility and move more centrally. The community, and the people and artefacts within it, are all resources for learning. Learning is both collective and individual. Social cognitive theory offers a complementary perspective on individual learning. Situated learning allows the incorporation of other learning perspectives and includes workplace learning and experiential learning. Viewing medical education through the lens of situated learning suggests teaching and learning approaches that maximise participation and build on community processes to enhance both collective and individual learning.

© Blackwell Publishing Ltd 2010.

Comment in

• Developmental aspects of medical competency and training: issues of curriculum design. [Med Educ. 2011]

PMID:

 

21155869

 

[PubMed - indexed for MEDLINE]