의대 과정동안 자기주도적학습 능력이 향상될까 줄어들까? (Acad Med, 2013)

의대 과정동안 자기주도적학습 능력이 향상될까 줄어들까? (Acad Med, 2013)

Does Medical Training Promote or Deter Self-Directed Learning? A Longitudinal Mixed-Methods Study

Kalyani Premkumar, MBBS, MD, MSc (Med Ed), PhD, Punam Pahwa, PhD,

Ankona Banerjee, MSc, Kellen Baptiste, MD, Hitesh Bhatt, MSc, and Hyun J. Lim, PhD

Campbell 등은 SDL을 Maslow가 '자기실현적 개인'이라고 칭한 고도로 주도적인 자기 학습자와 같이 학습 프로그램에 참여하는 것에 있어서 스스로 주도하고, 스스로 기획하는 행동이라 정의했다. Hammond와 Collins는 SDL을 학습자가 주도권을 쥐고 다른 사람의 지원과 협력하에 진행되는 프로세스라고 묘사했다. 그러나 가장 잘 정의된 것은 Knowles가 개개인이 이니셔티브를 쥐고, 다른 사람의 도움이 있거나 없는 상황에서 스스로의 학습요구를 진단하고, 학습목표를 설정하고, 인적 물적 학습자원을 찾아서 적절한 학습전략을 선택 및 도입하고 스스로의 학습결과를 평가하는 것이다.

Campbell et al1 define SDL as behaviors that range from participation in programmed learning to the self- initiated, self-planned activities of such highly directed self-learners as Maslow’s self-actualizing individuals.2,3 Hammond and Collins4 describe SDL as a process in which learners take the initiative, with the support and collaboration of others. But we believe the concept of SDL is best captured by Knowles5 as a process in which individuals take the initiative, with or without the help of others, in diagnosing their learning needs, formulating learning goals, identifying human and material resources for learning, choosing and implementing appropriate learning strategies, and evaluating learning outcomes."

왜 의학에서 SDL이 중요한가? Why is SDL important in medicine?"

SDL은 의학 분야에서 매우 강조되어왔는데, 예컨대 CanMEDS에서 scholar role을 보면, 의사들이 일생에 걸친 자기성찰적 학습을 해야 한다. 또한 ABMS와 WFME는 SDL을 의학교육에서 반드시 평가해야 하는 특징으로 보았다.

SDL has been increasingly emphasized in the medical field. For instance, the scholar role of the CanMEDS 2005 Physician Competency Framework emphasizes SDL by requiring physicians to demonstrate a lifelong commitment to reflective learning,9 and both the American Board of Medical Specialties and the World Federation for Medical Education include SDL as a characteristic that should be evaluated during medical education.10,11"

ACGME 역시 practice-based learning and improvement를 여섯 개의 핵심 역량 중 하나로 보았으며, 추가적으로 CME 역시 의사들이 자기주도적으로 스스로의 학습요구, 목표, 학습활동 선택 등을 잘 할 수 있다는 가정하에 이뤄지는 것이다.

The Accreditation Council for Graduate Medical Education, too, identifies practice-based learning (a form of SDL) and improvement as one of its six core competencies.12 In addition, continuing medical education for physicians is based on the assumption that physicians are self-directed leaders who can accurately predict their own learning needs, set goals, engage in appropriate learning activities, and regularly and accurately assess the outcomes.13,14"

SDL의 역량 

Competencies of SDL"

SDL의 역량은 여러 사람이 묘사했는데, 학습 격차에 대한 이해, 자신과 타인에 대한 평가, 성찰, 정보 관리, 비판적 사고, 비판적 평가 등이 있다.

The competencies of SDL have been described by many.5,15,16 They include proficiency in assessment of learning gaps, evaluation of self and others, reflection, information management, critical thinking, and critical appraisal.15"

이런 것들이 '자율성'을 의미하는 것 같지만, SDL은 동료 및 선생님들과 서로 정보를 교환하는 것을 포함한다.

Although all these characteristics seem to indicate autonomy, SDL involves interaction with peers and teachers to exchange information.17"

SDL이 교육될 수 있는가? Can SDL be taught?"

SDL은 종종 연속체로 묘사되곤 하는데, 한 극단에는 완전히 교사에게 의존적인 학생이, 다른 극단에는 완전히 자기주도적인 학생이 있다. 후자는 자신이 학습할 내용을 독립적으로 결정하고, 자원을 찾고, 문제를 해결하고, 평가할 수 있다. 그러나 한 상황에서 고도로 자기주도적인 사람도 새롭고 익숙하지 못한 환경에서는 매우 비-자기주도적이 될 수 잇다.

SDL is often described as a continuum, present in all individuals to some extent, with those who are least self-directed being totally dependent on the teacher for learning.5,16 The other end of the spectrum is the totally self-directed learner, who independently determines what is to be learned, identifies the resources, solves problems, and evaluates. It should be noted that a person who is highly self- directed in a particular situation may be very much less self-directed in a new and unfamiliar context.18"

Grow는 SDL의 단계 모델을 만들면서, 학습자를 자기주도적 학습의 네 단계 중 하나에 있다고 보았다.

Grow,16 in his staged SDL model, describes the learner, at any given time or learning situation/ context, to be in one of four stages: 

• dependent (stage 1), 
• interested (stage 2), 
• involved (stage 3), and 
• self-directed (stage 4)."

교육자들은 학습자가 어느 단계에 있는가를 진단하고 더 높은 단계로 준비히켜주어야 한다.

Educators need to diagnose the learner’s stage of self-direction and prepare the learner to advance to higher stages."

Grow에 따르면, 의존적으로 학습하는 것은 교수-학습의 학생중심이라는 원칙에 위배되는 것이지만, 일시적으로 의존적 관계를 촉진하는 것이 학습자를 더 높은 단계로 이끄는 것에 장애가 되지는 않는다.

According to Grow, although learning in a dependent mode goes against the principle of student-centered styles of teaching and adult learning, there is nothing demeaning or destructive in promoting temporarily dependent relationships as long as the purpose is to advance learners to higher stages."

SDL 준비도 측정 

Measuring SDL readiness"

SDL readiness를 측정할 수 있는 몇 가지 도구가 있다. SDLRS, OCLI, Ryan's, Fisher 등의 SDL readiness scale 등이다.

There are several instruments that have been developed to measure SDL readiness.15,19–23 The more widely used instruments are Guglielmino’s15,24 Self-Directed Learning Readiness Scale (SDLRS), Oddi’s19,20 Continuing Learning Inventory (OCLI), Ryan’s23 ability and importance scores, and Fisher and colleagues’18 SDL readiness scale."

SDLRS는 자기기입식 설문지로 다음의 구인을 평가한다.

The SDLRS consists of a self-report questionnaire of 58 questions and is one of the most common instruments used to assess SDL readiness.24 It measures eight constructs: 

• Openness to learning opportunities 

• Self-concept as an effective learner 

• Initiative and independence in learning 

• Informed acceptance of responsibility to one’s own learning 

• Love of learning 

• Creativity 

• Positive orientation to the future 

• Ability to use basic study and problem- solving skills"

질적분석 

Qualitative. 

연구 후반부에 인터뷰를 실시하였고, 여섯 명으로부터 반구조화 면접을 수행했다.

At the end of the study, all instructors in the medical school were invited to participate in interviews. Six instructors volunteered, and we conducted semistructured interviews with them."

녹취된 인터뷰와 포커스그룹은 세 명의 coder에 의해서 independently 분석되었고, 반복적인 토론을 통해서 합의달성

The recorded interviews and focus group discussions were transcribed. The transcriptions were independently examined for common themes by three coders (K.P., A.B., and another qualitative research expert). Repeated discussions were held until agreement among coders was attained."

입학 당시 SDL 준비도

SDL readiness and age at admission 

연령이 높아질수록 SDLRS 점수에 긍정적 효과가 있었다. 종합적으로, 더 나이를 먹은 학생이 더 점수가 높았다.

Age was considered to be a continuous variable in this study, and an increase in one year of age at admission had an overall positive impact on SDLRS scores. Overall, students who were older had significantly higher scores (P = .002) than did younger students."

SDL과 premedical university education 기간

SDL and years of premedical university education"

SDL 준비도의 변화

Changes in SDL readiness of medical students from admission to graduation."

입학 후 1년이 지났을 때 SDLRS점수에 유의미한 하락이 있었다. 입학시 점수보다 지속적으로 낮았다.

There was a significant drop (P < .001) in SDLRS scores in all cohorts one year after admission. The scores of all cohorts continued to be significantly lower than that at admission throughouttraining and at graduation."

SDL을 촉진하는 현 교육과정 내의 활동들

Activities in the current curriculum that promote SDL "

SDL에 배정된 시간을 중요시하여, 교육과정의 한 부분으로서 1학년 때 매일 오후는 SDL로 할당되었다. 그러나 지침이나 관리 없이 시간만 주는 것은 SDL을 오히려 악화시켰다.

The instructors and students identified some of the activities within the current curriculum that promote SDL: The time allocated for SDL—especially in the first year—was considered valuable. As part of the curriculum, a few hours of every afternoon in year 1 is earmarked for SDL. However, it was felt that being giventime, without direction and monitoring, deterred SDL."

SDL 촉진/악화 요인

Factors that facilitate/deter SDL 

두 가지 주제가 드러났다. 하나는 학습 환경과 관련된 것이고 다른 하나는 평가에 관련된 것이다.

Two themes clearly emerged: one related to the learning culture and environment and the other related to assessment."

SDL이 교육과정 전체에 걸쳐서 주요한 주제가 되어야 한다. 한 두 개의 과목만으로는 안된다.

Instructors felt that SDL has to be a theme throughout the curriculum, not introduced in just one or two courses."

SDL은 guide process로 여겨졌으며 SDL의 기술들은 교육될 수 있다

SDL was thought to be a guided process, and skills in SDL had to be taught."

SDL이 학년이 올라가면서 낮아지는 것에 대해서 교사나 학생 모두 전혀 놀랍지 않다는 분위기였다.

Towards the end of the focus group/ interviews, students and instructors were told that preliminary findings of this study seemed to indicate that SDL readiness was decreasing with increasing years. Both groups were not surprised at the findings:"

SDLRS scores, adult population, other health professions, other medical schools."

SDL readiness and gender."

SDL readiness and age. 

나이를 더 먹은 학생이 어린 학생보다 유의미하게 높았으며 이는 Reio와 Davis, Kell과 Van Deursen의 결과와 일치한다. (50세까지는 SDL이 향상됨) 학습에 대한 선호는 과거의 학습경험과 학습과정을 통제할 수 있다는 자신감에서 나온다.

Older students had significantly higher scores than younger students. This is consistent with the findings of Reio and Davis38 and Kell and Van Deursen41 and lends further support that SDL has a positive developmental trajectory until the 50s, consistent with SDL theory.42,43 The learning preference has been attributed to previous learning experience and confidence in controlling the learning process.44 "

SDL readiness and premedical training"

premedical training과의 Harvey 등의 연구와 대조되는데, 여기서는 SDL점수가 premedical education 수준이 높을수록 높았다.

This finding is in contrast to that of Harvey et al,39 who found a significant positive trend in SDL scores (using SDLRS, the Oddi Continuing Learning Inventory [OCLI], and Ryan’s [ability] scores) associated with the highest level of premedical education achieved (undergraduate only, master’s, or doctoral)."

SDLRS scores with increased medical training."

SDL점수가 1학년 말에 유의미하게 하락했다.

Our findings indicate that SDL readiness scores decreased significantly at the end of one year."

이러한 연구 결과는 U of Toronto의 결과와도 비슷하다.

our findings are similar to the findings of researchers at the University of Toronto Faculty of Medicine, who did a cross- sectional study on first- and second-year medical students (N = 280). Of the three instruments that they used (SDLRS, OCLI, and Ryan), the scores obtained with Ryan’s instrument showed a decrease with more training.39"

이런 차이는 어떻게 설명가능할까?

How can these differences be explained?"

이러한 차이는 어떻게 설명할 수 있을까? Knowles는 학습을 교수주도과 자기주도를 양측에 둔 연속체로 묘사하였다(pedagogical - androgogical). 이 연속체는 학습자가 학습에 대하여 얼마나 통제권을 가지고 있으며, 학습목표를 달성하기 위하여 필요한 평가와 전략에 대해 얼마나 자유도를 가지는지에 의해 달라진다. 예컨대 특정한 학습 영역에서 자기주도적이 되기 위해서는 학습자는 특정 수준 이상의 지식을 가지고 있어야 한다. SDL에 대해 얼마나 준비가 되어있느냐는 학생마다 매우 다르고, 이는 학생마다 경험이 다르기 때문이다. 학생이 지식이 적을 때는 높은 수준의 구조화가 필요하다. SDL에 대한 준비도와 틀에 짜여진 교육시간에 대한 선호도와는 분명한 역의 상관관계가 있다. 학부 교육과정동안 학생들은 과도한 정보를 주입당하는데, 학생들은 그 시간동안 자기들의 스스로의 흥미에 대해 공부할 시간이 거의 없다. 따라서 의대 기간동안 SDLRS가 떨어지는 것이 놀라운 것은 아니다.

How can the differences in SDLRS scores with training be explained? Knowles5 describes learning as a continuum with teacher-directed (pedagogical) learning at one end and self-directed (androgogical) at the other. This continuum can be explained in terms of how much control the learner has over learning and the amount of freedom given to evaluate and implement strategies to achieve learning goals. In medicine, the learning environment tends to keep students in the pedagogical end of the spectrum. For instance, to be self-directed in a specific content area, a person must possess a certain level of knowledge. The readiness for SDL is variable in any given student population, as each student enters medicine with a different academic background. When students have a low level of knowledge, they prefer a high degree of structure. It has been shown that there is a definite inverse correlation between SDL readiness and student preference for structured teaching sessions.47,48 Throughout undergraduate training, students are overloaded with information. Moreover, the competencies required are well defined by regulatory bodies, and there is very little time for students to pursue their own interests. As our faculty note, it is therefore not surprising that SDLRS scores decrease with training."

Knowles에 따르면 학생과 교사 모두 SDL기반 교육과정 도입에 필요한 스킬을 갖출 필요가 있다.

According to Knowles,5 both teachers and students have to possess the skills necessary for the implementation of an SDL-based curriculum."

• role of facilitators"
• learning environment that is collaborative rather than competitive."
• diagnose learning needs"
• help learners diagnose their own needs.5"
• Training plays a key role"

학생과 교사의 준비가 부족한 것 외에 다른 SDL의 장애물로는 Shokar는 "전문성, 교육과정, 법, 조직 내규, 외부 제약, 시간 제약, 학습할 내용 등으로부터 오는 제한"이라고 했다.

Apart from lack of teacher and student preparation, other factors may serve as barriers to SDL. Shokar et al50 list some of these barriers as “restrictions imposed by professional, curricular, legal, and institutional requirements, statutory educational regulations, time constraints, and the need to ensure that specific content is covered.”"

모든 상황에 SDL이 적용가능한 것이 아님을 염두에 둘 필요가 있다. 학생이 과거 경험이 매우 적거나 학습의 초점이 과목 그 자체보다는 내용(구체적 학습목표)에 있을 때 SDL은 적절하지 않다. 학부의학교육은 - 특히 1학년은 - 거의 지식에 대한 기반이 약하고 따라서 학생들이 교사-의존적이 되는 것은 이해할 만 하다.

One must also remember that not all situations are applicable for SDL. SDL may not be appropriate in situations where the student is new or has very little previous experience of the subject and when the focus of learning is on the content (e.g., specific learning objectives) rather than the subject itself.47 In undergraduate medical training— especially in the first year—most students have very little foundational knowledge. It is therefore understandable that students are more teacher-dependent and require that the education program be more structured."

SDL에 영향을 주는 요인들이 복잡함을 고려할 때 많은 모델이 SDL을 대표한다. Garrison의 모델, Brocket과 Hiemstra의 모델, Candy의 모델.

Given the complexity of factors that influence SDL, a number of models have been proposed to represent SDL. 

• Garrison’s51 model focuses on three psychological constructs: self- monitoring (cognitive responsibility), self-management, and motivation (see Figure 2). 
• Self-monitoring refers to the ability of learners to monitor both their cognitive and metacognitive processes. 
• Self-management focuses on goal setting, use of resources, and external support for learning. 
• Motivation has two dimensions: entering and task motivation. 
• Entering motivation is what compels the learner to participate in the learning process, whereas 
• task motivation is what keeps the learner on task and persisting in the learning process. To promote SDL, each of these constructs needs to be addressed."

• Brocket and Hiemstra’s52 model of SDL (see Figure 2) focuses on learner control of responses to a situation even if there is no control over the circumstances; the model considers SDL and learner self-direction as two dimensions, with personal responsibility connecting the two. To facilitate SDL, focus on promoting personal responsibility is required."

• Candy’s53 SDL model (see Figure 2) illustrates two interacting laminated (layered) domains. One dimension relates to the amount of control within an institutional setting, with one end of the continuum showcasing teacher control and the other learner control. The second dimension relates to amount of control over informal learning: autodidaxy. In this model, one needs to help the organization and its teachers choose appropriate strategies based on the content and level of knowledge of students, and to facilitate movement of students along the continuum."

다갈래의 전략이 필요하다. 학생이 SDL궤도를 따르도록 도와줄 수 있는 네 가지 원칙을 요약하였음.

From the different SDL models it can be deduced that a multipronged approach has to be taken to promote SDL in students. Francom54 summarizes four principles instructors can use to help students move along the SDL trajectory: 

• Match the level of SDL required in learning activities to student readiness 

• Progress from teacher to student direction over time 

• Support the acquisition of subject matter knowledge and SDL skills together 

• Have adults practice SDL in the context of learning tasks"

학생이 학습에 대한 책임을 지게 하는 교육자의 여섯 가지 역할을 제시하였음

Hiemstra55 describes six foundational roles that instructors need to take on to enable students to adopt personal responsibility for their learning: 

• Content resource (sharing expertise and experiences using various forums) 

• Resource locator (locating and sharing various resources to meet student needs)"

• Interest stimulator (arranging for resources that maintain student interest in the subject, e.g., games, discussions; guest presentations) 

• Positive attitude generator (through positive reinforcement; prompt, useful feedback) 

• Creative and critical thinking stimulator (through study groups; journal writing; logs; simulation; role-play) 

• Evaluation stimulator (learner evaluation and promotion of self-evaluation)"

Figure 2 Three models of self-directed learning (SDL).51–53 See the text for a discussion of these models. Used with permission."

---

Acad Med. 2013 Nov;88(11):1754-64. doi: 10.1097/ACM.0b013e3182a9262d.

Does medical training promote or deter self-directed learning? A longitudinal mixed-methods study.

Premkumar K1, Pahwa P, Banerjee A, Baptiste K, Bhatt H, Lim HJ.

Author information

• 1Dr. Premkumar is curriculum consultant and faculty development specialist, and associate professor, Department of Community Health and Epidemiology, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada. Dr. Pahwa is professor, Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada. Ms. Banerjee was a third-year master's student, Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada, at the time this article was written. Dr. Baptiste was a fourth-year medical student, College of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada, at the time this article was written. Mr. Bhatt is biostatistician, University of Alberta, Edmonton, Alberta, Canada. When this article was written, he was biostatistician, Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada. Dr. Lim is professor, Department of Community Health and Epidemiology, University of Saskatchewan, Saskatoon, Saskatchewan, Canada.

Abstract

PURPOSE:

The School of Medicine, University of Saskatchewan curriculum promotes self-direction as one of its learning philosophies. The authors sought to identify changes in self-directed learning (SDL) readiness during training.

METHOD:

Guglielmino's SDL Readiness Scale (SDLRS) was administered to five student cohorts (N = 375) at admission and the end of every year of training, 2006 to 2010. Scores were analyzed using repeated-measurement analysis. A focus group and interviews captured students' and instructors' perceptions of self-direction.

RESULTS:

Overall, the mean SDLRS score was 230.6; men (n = 168) 229.5; women (n = 197) 232.3, higher than in the average adult population. However, the authors were able to follow only 275 students through later years of medical education. There were no significant effects of gender, years of premedical training, and Medical College Admission Test scores on SDLRS scores. Older students were more self-directed. There was a significant drop in scores at the end of year one for each of the cohorts (P < .001), and no significant change to these SDLRS scores as students progressed through medical school. Students and faculty defined SDL narrowly and had similar perceptions of curricular factors affecting SDL.

CONCLUSIONS:

The initial scores indicate high self-direction. The drop in scores one year after admission, and the lack of change with increased training, show that the current educational interventions may require reexamination and alteration to ones that promote SDL. Comparison with schools using a different curricular approach may bring to light the impact of curriculum on SDL.

PMID:

 

24072133

 

[PubMed - indexed for MEDLINE]