의과대학생들은 임상실습에서 어떻게 자기주도적인 방법으로 학습할까? Design-based research (Med Educ, 2005)

의과대학생들은 임상실습에서 어떻게 자기주도적인 방법으로 학습할까? Design-based research (Med Educ, 2005)

How can medical students learn in a self-directed way in the clinical environment? Design-based research

Tim Dornan,1 Judy Hadfield,1 Martin Brown,2 Henny Boshuizen3 & Albert Scherpbier4

영국의 GMC는 의과대학생에게 자신의 학습 방향을 스스로 결정하라고 하면서 의학교육을 새로운 트랙에 올려놓았다. 성인학습자 원리에 따르면 - 이 권고안의 근간이 되는 - 학습자와 그의 열망은 교수-학습 공식에서 중요한 위치를 갖는다. 그러나 '자기주도학습'이란 말은 단일한, 일반적으로 동의되는 의미를 가지고 있지 않는다. GMC는 스스로의 학습요구를 조직하고 관리하는 것을 의미하였으며, 성인학습자 원리를 처음 주장한 Knowles는 SDL을 스스로의 동기를 찾고 교사와 보다 동등한 관계를 갖는 것을 의도하였다.

The UK General Medical Council (GMC) set medical education off on a new track when it called for medical students to direct their own learning.1 Adult learning principles ,2 which underpin that recom- mendation, have served a useful role in putting the learner and his or her individual aspirations back in the teaching)learning equation .3 However, the term self-direction does not have a single, generally agreed meaning. The GMC meant organising and managing one s own learning needs.’1 Knowles, who first articulated adult learning principles, meant finding one’s own motivation and having a more equal relationship with teachers.2"

PBL에서의 자기주도적 행동 성향이 임상교육현장으로 잘 전이되지 않는 것은 (1)낯섦, 복잡성, 권력관계, 정서적 요인 등이 젊은 학습자들로 하여금 임상환경에서 자발적인 행동을 어렵게 하며, (2)외부의 방향제시가 필요하다는 결론에 이르게 한다.

The limited transfer of self-directed behaviour from PBL to placement learning6 led us to hypothesise that: unfamiliarity, complexity, power differentials and 1 emotional factors make it hard for young learners to act autonomously, and more external direction is needed in the clinical 2 environment."

iSUS는 학습 관리 시스템으로서, 교육과정 목표를 알고 있고, 각 학생에 대하여 그 목표에 대한 자기보고를 지속적으로 추적하여 전체 그룹과의 향상정도를 비교하고 관련된 교육을 받을 수 있게 도와준다. 학생은 예컨대 신장요로계 질환을 더 학습해야 한다고 할 때, 신장투석 클리닉을 관련 학습기회의 장소로 찾아주고, 그 장소에 참석할 수 있도록 예약을 해준다. 여기까지 몇 번의 클릭과 7초 정도만 소요된다. iSUS는 1명의 학생에게만 공간이  가능하다는 것을 알고, 다른 학생의 예약을 차단해준다. 이전 학생으로부터의 피드백은 유용한 선택의 길라잡이가 된다. 학생이 다음 번 로그인하면 iSUS는 그 클리닉에서의 경험에 대해 코멘트하도록 권한다.

Intelligent signup system ) iSUS The learning management system, described in detail elsewhere,12 is intelligent in that it knows the curriculum objectives, keeps track of each student’s self-reported progress towards them, compares pro- gress against the whole peer group, suggests signups or other relevant experiences, and helps access them. A student might, for example, see they need to learn more about renal ⁄ urological disease, particularly chronic renal failure, identify the predialysis clinic as a relevant learning opportunity, and reserve a place to attend it. That would take 7 mouse-clicks and a few seconds. iSUS would know there was space for only 1 student to attend, and restrict booking to someone who had no other timetabled activity. Feedback from previous students would be available online to guide the choice. The next time the student logged on, the system would ask for a free text comment about their experience at the clinic."

질적연구방법

Textual materials were coded, back-referenced to the complete transcripts, assembled into an evolving interpretation, and reduced to a single narrative using NVivo software (QSR, Doncaster, Victoria, Australia). Three types of statement were identified: 

• 1 Statements describing the behaviour of a student on a specific occasion in a practice setting, coded as performing , observing , discussing or being taught and subcoded as active ( I did ), passive ( I was directed ) or mutual ( We did ). 
• 2 General descriptions of learning were coded for the degree of autonomy expressed by the student, and sources of guidance or support. 
• 3 Conceptualisations of self-direction. "

한 명의 연구자가 일차 코딩을 수행하고, 다른 연구자들은 자료를 읽고 그 코딩의 bias, 생략된 부분, 의견의 차이 등을 찾아내였다. 최종 결과는 3 가지의 statement의 카테고리를 삼각층량함으로서 도출하였다.

One researcher carried out the primary coding. Three others read the material and sought bias in his coding, omissions, and disconfirmatory statements. The final conclusions were arrived at by triangulation between the 3 categories of statement, representative examples of which are cited."

1. 임상환경에서 학생의 행동유형

1. Behaviour of students in the clinical environment 

1.a. Performing 

1.b. Observing"

1.c. Discussing 

1.d. Being taught 

2. 학습에 대한 일반적 묘사

2. General descriptions of learning 

2.a. Learning autonomously 

2.b. Learning with support 

2.b.1a. Staff behaviours"

2.b.1b. Guidance"

2.b.1c. Facilitation"

2.b.1d. Feedback"

2.c. Being told what to learn"

3. 자기주도학습의 개념

3. Conceptualisations of self-direction 

3.a. Definition of self-direction"

3.b. The value of self-direction"

3.c. Prerequisite conditions for self-direction"

3.c.1a. Objectives"

3.c.1b. Student attributes"

3.c.1c. The transition into self-direction"

3.c.1d. Support by teachers"

자기주도학습은 운전석에 앉는 것과 같아 자신의 학습에 책임을 지는 것이다. 종종 그 과목에서 부족했던 부분을 보충하는 것일 수도 있지만, 비효율적인 학습방법으로 인식되기도 한다. 한 학생은 direction (명확한 목표가 있는 것)을 motivation (direction이 선행될 때 가능한 것)과 구분하기도 했다. 자율이란 '어떻게'를 선택하는 것이었으며 '무엇을 학습할 것인가'를 결정하는 것을 의미하지 않았다. 학습의 다양성을 인정하면서도 응답자들은 핵심 목표를 다루고 싶어했다.

Self-direction involved being in the driving seat, or being responsible for one’s own learning. At times, it could be a compensation for deficiencies in the course, but that was seen as an inefficient way of learning (3.a.1). One respondent distinguished direction – having clear objectives – from motiva- tion – for which direction was a prerequisite (3.a.2). Autonomy meant being able to choose how, rather than what, to learn (3.a.3). Whilst valuing diversity of learning, respondents were concerned to cover coreobjectives. "

교육과정 평가에서 처음에는 학생의 태도에 실망했지만, 점차 '자기주도적 태도'에 대한 질문을 갖게 했다. 우리 학생들은 학습의 개념화와 행동적 차원에서 능동적이었지만, 교사가 그들을 지지해줄 때 더 능동적이고 동기부여를 받았다. 다양한 형태의 지원이 가능하다.

Curriculum evaluation has moved us from disap- pointment in students’ behaviour to a more ques- tioning attitude towards self-direction. Our students were active in their actions and conceptualisations of learning. However, they were most active and motivated when teachers supported them. Support took several forms:"

• organisational: opening up learning opportunities, particularly those that involved students in patient care; 
• pedagogic: suggesting objectives or methods, training skills, giving feedback, explaining con- cepts, and 
• affective: giving permission, helping students through the transition to a more independent learning style, nurturing, and placing demands."

본 연구는 문제바탕학습 방법이 왜 임상교육으로 자동적으로 전이되지 않는가를 설명해준다. 방향제시와 동기부여의 원천, 그리고 그들의 관계가 PBL과 임상교육에서 차이가 있었다. 튜터가 관리하는 PBL 그룹에서 불확실성은 그들로 하여금 지적인 호기심을 유발하고 학습목표로 이끈다.

This study confirms and helps explain our previous observation that problem-based methods do not transfer automatically to the clinical environment.6 The sources of direction and motivation, and their interrelationship, are different in PBL and place- ment learning. Uncertainty in a tutored PBL group in a seminar room motivates students by generating epistemic curiosity 14 and leads them to learning objectives."

임상환경은 세미나실보다 더 위협적이다. 여기서 불확실성은 동기를 부여해주기보다는 동기를 깎아먹으며, 지지적인 의사와의 사회적 관계가 학생들에게 더 동기부여가 되었다. 불행하게도, PBL과 임상교육 간의 교차(crossover)가 없는 것은 임상환경에서 학생들에게 주어진 학습목표가 무엇인지를 애매하게 만든다. iSUS는 동기부여의 잃어버린 한 조작을 찾게 해준다.

The clinical environment is much more threatening than the seminar room. Thus, uncer- tainty is more of a demotivator than a motivator. Social interaction with a supportive practitioner gave our students the direction they needed to become motivated. Unfortunately, the lack of crossover between problem-based and placement learning leaves our teachers and learners very unclear about the intended learning outcomes of their clinical placements.6 iSUS, it seems, can provide the missing piece of the motivational jigsaw."

본 연구와 다른 연구들은 자기주도적 학습이 임상환경에서의 기본적 전문성 교육에는 적용하기 어려움을 보여준다. 또한 Knowles 자신조차도 나중에는 정서적 지지가 중요함을 강조한 바 있다. 다른 연구자들은 자기주도적 행동과 주변 환경과의 상호작용을 강조한다. 이는 교육에 대한 인지적 이해(cognitive perception)에서는 잘 드러나지 않았던 것이다. Miflin 등은 교사가 임상교육의 필수적 조건임을 찾아낸 바 있다. PBL에 cognitive foundation을 제시한 Schmidt조차도 나중에는 임상환경에서 진정으로 자기주도적이 되기 얼마나 어려운지, PBL에서 임상환경으로 전이되는 것이 얼마나 어려운지 강조하기도 했다.

Our own and others’ research leads us to suggest that self-direction , as literally applied by many of our teachers, is inapplicable to basic professional education in the clinical environment. It is note- worthy that Knowles himself re-emphasised the place of affective support in late publications.15 Other writers have emphasised the interaction between self-directed behaviour and contextual factors,16 which are less emphasised in cognitive conceptions of education17 than new social theories.18 Miflin and colleagues found, like us, that the teacher is a vital condition for clinical learning.5 Their analysis anti- cipated, and has strong similarities with, our own critique of self-direction. Schmidt, who gave the problem-based method its cognitive foundation, later reaffirmed its benefits but recognised how difficult it is to develop truly self-directed behaviours and transfer them from PBL to the clinical envi- ronment.19"

우리는 임상교육을 PBL과 상보적일 수는 있어도 서로 별개의 것으로 바라보아야 한다는 결론에 이르렀다. PBL에서는 동료그룹 내에서라도 자율이 핵심이지만, 임상교육에서는 지지적 참여가 핵심 조건이 된다.

We conclude that placement learning should be seen as separate from, although complementary to, PBL. Whereas autonomy (albeit within a peer group) is key to PBL, supported participation is a core condition for placement learning."

적절한 지원이 있으면 의과대학생들은 매우 능동적인 학습자가 될 수 있으며, Harden 등은 이를 직무기반학습 이라는 새로운 관점에서 보았다.

Harden et al. approached the same problem from a different angle when they devised task-based learning .20"

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Med Educ. 2005 Apr;39(4):356-64.

How can medical students learn in a self-directed way in the clinical environment? Design-based research.

Dornan T1, Hadfield J, Brown M, Boshuizen H, Scherpbier A.

Author information

• 1Hope Hospital, University of Manchester School of Medicine, Stott Lane, Salford, Manchester M6 8HD, UK. Tim.Dornan@Manchester.ac.uk

Abstract

AIM:

This study aimed to establish whether and under what conditions medical students can learn in a self-directed manner in the clinicalenvironment.

METHOD:

A web-based learning management system brought 66 placement students, in a problem-based learning (PBL) medical curriculum, into closer touch with their clinical learning objectives and ways of achieving them. Free response comments from 16 of them during the 7 weeks they used it, transcripts of group discussions before and after the period of use, and responses from all 66 students to a questionnaire were analysed qualitatively.

RESULTS:

Students were rarely fully autonomous or subservient. They valued affective and pedagogic support, and relied on teachers to manage their learning environment. With support, they were motivated and able to choose how and when to meet their learning needs. The new system was a useful adjunct.

CONCLUSIONS:

Self-direction, interpreted literally, was a method of learning that students defaulted to when support and guidance were lacking. They found "supported participation" more valuable. Learning in the clinical environment was a social process with as many differences from, as similarities to, PBL.

Comment in

• Self-directed learning--the importance of concepts and contexts. [Med Educ. 2005]