의과대학 교육과정 중 자기주도학습 역량 향상을 위한 현실적 전략(IJSDL, 2014)

의과대학 교육과정 중 자기주도학습 역량 향상을 위한 현실적 전략(IJSDL, 2014)

PRACTICAL STRATEGIES TO PROMOTE SELF-DIRECTED LEARNING IN THE MEDICAL CURRICULUM

Dirk Morrison and Kalyani Premkumar

---

근거중심의학의 저명한 선구자인 David Sackett은 SDL이 왜 다급한지 다음과 같이 요약했다.

David Sackett, a well-known pioneer of evidence-based medicine, famously summed up one of the major reasons that development of self-directed learners is increasingly being recognized as an urgent need: 

당신이 의과대학에서 배운 것중에 절반은 졸업 후 5년 이내에 사라지거나 틀렸음이 증명될 것이다. 문제는, 거기에 해당할 것들이 무엇인지 알려줄 수 있는 사람이 아무도 없다는 것이다. 따라서 가장 먼저 배워야 할 것은 스스로 학습하는 방법이다.

Half of what you'll learn in medical school will be shown to be either dead wrong or out of date within five years of your graduation; the trouble is that nobody can tell you which half -- so the most important thing to learn is how to learn on your own. (Cited in Daily & Landis, 2014, p. 2066)

Daily, J. A., & Landis, B. J. (2014) The journey to becoming an adult learner: From dependent to self- directed learning. Journal of the American College of Cardiology, 64 (19), 2066-2068. Retrieved from http://content.onlinejacc.org/article.aspx?articleID=921687

---

SDL이 평생학습의 중요한 원칙이라는 것과 평생학습이 보건의료직에 대해 일반적으로 기대되는 점이라는 것은 자명해보인다.

It seems intuitively obvious that SDL is an important principle of lifelong learning (Candy, 1991) and that lifelong learning is a general expectation for the health professions;

SDL의 가치는 높이 평가받지만, 적어도 원칙에 있어서 어떻게 UME, GME, CPD라는 의학교육 연속체에서 SDL을 증진시키고 실현할 것인가에 대해 다룬 문헌은 거의 없다. Premkumar의 최근 종단연구에서 University of Saskatchewan’s College of Medicine 학생들은 SDLRS나 LPA로 측정했을 때 UME동안 입학때에 비해서 자기주도학습성이 떨어졌다.

While SDL is valued, at least in principle, along the medical education continuum (undergraduate, postgraduate and continuing professional education), there is a clear lack of documentation regarding how to promote and actualize SDL. A recent longitudinal study (Premkumar et al., 2013) of undergraduate medical students at the University of Saskatchewan’s College of Medicine assessing changes in self-directed learning readiness, as measured by the Self-Directed Learning Readiness Scale (SDLRS) or Learning Preference Assessment (Guglielmino, 1978; Guglielmino & Associates, 2010) indicated a significant drop during undergraduate medical training, as compared to measures of SDL readiness at admission.

의과대학에 들어온 학생이 일반적인 학생집단에 비해서 SDLRS가 높다는 점을 비추어보면, 의과대학 교육과정의 특정 요소들(인지적 과부하, 평가유형, 시간 부족) 등이 초반의 높은 자기주도성을 하락시키는 것으로 추정된다.

Given that entering students of health professions have been shown to have higher SDLRS scores as compared to the general student population (Premkumar et al., 2013), it is speculated that specific factors in the traditional orientation and structure of the medical curriculum (e.g., cognitive overload, assessment types, lack of time, etc.) may erode an initial positive orientation toward self-directed learning.

Reversing the Trend: Integrating SDL principles and Strategies Into the Curriculum

전략 1: SDL에 대한 오리엔테이션 제공

Strategy 1: Provide an Orientation to SDL

학생과 교수 모두 SDL기술과 역량을 발휘하고 있으나, 그렇게 이해하고 있지는 않을 수 있다.

It is likely that many students and faculty exercise skills and competencies of SDL but may not understand them as such

교육과정 시작시에 SDL의 목표와 원칙에 대해서 명확히 설명해주기 위한 노력을 충분히 들여야 한다.

어떻게 SDL이 학생들에게 기대되고 있으며, 이것이 전체 교육과정에서 중요한 점이라고 명확히 설명해주는 것, 그리고 일관된 교육 주제 등이 이러한 오리엔테이션을 잡는데 중요할 것이다.

Clearly explaining how SDL is an expectation of all students and that it is an integral part of the overall curriculum, a consistent pedagogical theme, will be an important part of such an orientation (Daniels, 2011).

전략 2: 학습자의 SDL준비도와 기술을 확인하라.

Strategy 2: Identify Individual Learner's SDL Readiness and Skill Level

SDLRS가 있다.

The SDLRS instrument,

Grow의 네 단계 모델을 활용하는 방법도 있다.

The application of Grow's (1996) Staged Self Direction Model (stage 1: low self-direction - stage 4: high self-direction) may also provide some insight here,

SDL준비도는 상황이나 교육내용에 따라서 달라질 가능성이 높다. 학습자의 SDL준비도를 알고 거기에 맞춰서 교육을 조절해야 한다. 예컨대 Dynan Cate rhee는 SDLR 점수에 따라 구조화된 혹은 비구조화된 학습환경으로 학습자를 구분하고 두 집단 모두에서 SDLRS 점수가 상승함을 확인했다.

SDL readiness will likely vary based on situation and topic. It would be important to understand learner readiness to engage with SDL and make adjustments to the curriculum. For example, Dynan, Cate, and Rhee (2008), in reviewing a research study that grouped learners in structured and unstructured learning environments based on their SDLR scores found that the SDLRS scores increased in both groups.

전략 3: SDL역량의 발달을 명확히 하고 촉진하라

Strategy 3: Clarify and Promote the Development of SDL Competencies

Weimer가 지적한 바와 같이 SDL에 필요한 핵심 역량은 다음을 포함한다. 

As Weimer (2010) points out, a core set of competencies for SDL would include the ability for learners to “

• assess the demands of the task, 
• evaluate their own knowledge and skills, 
• plan their approach, 
• monitor their progress, and 
• adjust their strategies as needed” (p. 5). 

다른 것으로는..

Other competencies would include: “

• proficiency in assessment of learning gaps, 
• evaluation of self and others, 
• reflection, 
• information management, 
• critical thinking, and 
• critical appraisal” (Premkumar et al., 2013).

이러한 기술을 연습할 분명한 지침과 기회를 전 교육과정에 걸처 제공하는 것이 중요하다. 또한 Wimer는 연구를 살펴보면 SDL skill은 직접적 교육보다는 우연에 의해서 향상되며 메타인지 기술을 갈고닦을 필요가 있음을 언급했다.

Explicitly providing instruction and opportunities to practice these skills, across the curriculum, will be critical if SDL is to be successfully integrated. In addition, Weimer (2010) states that research indicates SDL skills are developed much more efficiently by direct instruction than by happenstance, and includes the need to hone metacognitive skills.

• Assess the task by being more explicit than you may think necessary. 

• Evaluate how well they’re equipped to do the task by providing opportunities for self-assessment early and often. 

• Plan an appropriate approach by first implementing a plan you’ve provided and then by creating their own plans. 

• Apply selected strategies and monitor progress by having students do guided self-assessments.

• Adjust their strategies by encouraging them to analyze the effectiveness of what they have done.

전략 4: 자신의 관심사를 추구할 기회를 제공하라

Strategy 4: Provide Opportunities to Pursue Own Interests

학습자가 학습과제를 다양한 전략과 다양한 방법으로 접근하게끔 장려하는 것은 중요하나, 이에 못지 않게 학습자들이 스스로의 관심사를 능동적으로, 체계적으로 쫒도록 하는 것도 중요하다. 이는 SDL을 학습과 교육의 구조 속에 넣는 것으로 달성될 수 있다.

While it is important to encourage learners to approach a task in different ways using different strategies, it is also critical that learners actively and methodically pursue their own interests. This may be achieved by framing SDL in the way learning and instruction is organized.

현재 의과대학은 주로 4학년때 관심있는 자신의 전공과나 분야 경험을 쌓을 수 있다. 예컨대 학생들은 구체적인 관심영역을 개별 코스에서 쫒을 수 있다. 이 SDL과정은 적절한 평가 요소를 포함시켜 공식화 될 수 있다.

Currently, medical students are usually given opportunities in their senior years to pursue experiences in medical specialities or areas that are of interest to them However, more and more varied opportunities need to be provided throughout the curriculum. For example, students can be given opportunities to pursue specific topics of interest within individual courses; this SDL process needs to be formalized with incorporation of an appropriate assessment component.

학습자가 자신의 문제를 스스로 만들어서 학습 전략을 활용할 수 있는 환경을 제공하는 것은 논리적으로 합당할 뿐만 아니라 authenticity와 학습자가 심화 학습을 위해 참여할 수 있는 길을 만들어준다. 

As often as is reasonable, providing strategies and learning contexts whereby learners formulate their own problems (individual or collective) to be researched and solved, will provide another layer of authenticity and, potentially, increase learner engagement and deeper learning.

전략 5: 협력적 학습을 활성화시키라

Strategy 5: Activate Collaborative Learning

SDL이 많은 경우 자율학습과 동일한 의미로 사용되지만, 이는 사실이 아니다. 비슷한 생각을 하고 비슷한 동기를 갖는 동료들과 함께 공부하는 것은 SDL의 원칙에 위배되는 것이 아니다. 팀바탕 학습의 다양한 기회를 제공하고, 동료끼리 가르치고 프로젝트나 문제를 기반으로 한 그룹 학습은 개개인의 학습 전략과 그룹 협력적 프로세스를 통하여 SDL의 원칙을 더 강조할 수 있다. 

While SDL is seen by many as synonymous with autonomous learning (insinuating a “learner learning alone”), nothing is farther from the truth: opportunities to learn with other like-minded, like-motivated peers is not antithetical to the principles of SDL. Providing multiple and varied opportunities for team-based learning, peer teaching and project or problem-based group learning would underscore the fact that the principles of SDL can be actualized via individual learner strategies and collaborative group processes.

의학 교육과정의 심화 이해를 달성하기 위해 Barrett과 Moore는 학습자들이 문제에 깊이 관여하면서 아이디어를 공유하고, 다양한 관점과 해석을 접하고, 공통의 의미를 향유함으로서 능동적으로 지식을 생산, 재생산하는 것이 필요하다고 주장하였다. 이는 상호작용/협력/의사소통을 통해서 가능하다.

If deep understanding of the medical curriculum is to be achieved, Barrett and Moore (2011) argue for the need to create environments and processes whereby learners actively create and re-create knowledge together, by sharing ideas, confronting divergent views and interpretations, embracing shared meanings and by deeply engaging with learning problems in “interactive, collaborative, communicative ways” (Armitgage, 2013, p. 5).

전략 6: 의미있는 성찰을 장려하기

Strategy 6: Encourage Meaningful Reflection

따라서 학습자들이 자신의 SDL에 대해서 능동적, 비판적으로 성찰하려면 개념적, 조작적 프레임워크를 제공하여 평가 틀로 활용해야 한다. 이 능동적 성찰의 최종 목표...

It will be important, therefore, to provide a conceptual and operational framework, an evaluative scaffold, if you will, whereby the learner can actively and critically reflect on their SDL. End goals of this active reflection might be to 

• look for insights into how one learns best, 
• evaluate and then make adjustments in personal learning strategies, 
• pursue promising avenues of investigation and interest, 
• reflect on action (i.e., retrospective analysis) and 
• reflect in action (a mindfulness while one is executing an action) (Schon, 1983).

Day One이나 Evernote, e-portfolio 등을 사용할 수 있다.

application journal such as Day One (Bloom Built, 2014) or Evernote (Evernote Corp., 2008) 

Regularly annotating e-portfolio entries

전략 7: SDL을 통합시키기 위해서 학생 평가를 바꾸라

Strategy 7: Alter Student Assessment To Integrate SDL

성찰 없이는, MCQ, 빈찬 캐우기, 단답형 등과 같은 평가방식은 효율성은 높을지 모르나 SDL의 기회는 거의 제공하지 않는다. 더 정확히는 자기주도적 평가가 안된다.

With a little reflection, it is clear that multiple choice, fill-in-the-blanks, short answer and other such assessment tools, while affording efficiencies (e.g., machine- graded), offer little to create opportunities for SDL, or, more accurately, self-directed assessment.

Driessen 등은 포트폴리오를 성공적으로 사용하는 조건을 언급했다.

Driessen et al. (2005) outline some of the necessary conditions for the successful use of portfolios in medical education; what is especially important in this study is that they were able to show that “portfolios are a potentially valuable method of assessing and developing students’ reflective skills in undergraduate medical training…” (p. 1230). If this method is to be used to encourage and support SDL, then necessary conditions need to be fulfilled, including: 

• “an appropriate portfolio structure, 
• an appropriate assessment procedure, 
• the provision of enough new experiences and materials, and 
• sufficient teacher capacity for adequate coaching and assessment” (Driessen et al., 2005, p. 1230).

전략 8: SDL을 진행할 시간을 주라

Strategy 8: Make Time Available for the Processes of SDL

Goodlad는 교수자는 학교의 상황을 만들고, 학교의 상황에 따라 만들어진다. 시간은 사용할 수 있는 가장 중요한 학습 자원으로서, 시간을 어떻게 사용하는가가 학습 기회의 차이를 가져온다. 따라서 시스템은 이 소중하고 제한된 자원의 활용(또는 오용)되는 것에 영향을 주며, SDL활동과 절차를 위한 시간을 배분하기 위해서는 Radical한 사고의 전환이 필요하다.

Goodlad (1984) points out, “teachers both condition and are conditioned by the circumstances of schools...; time is virtually the most precious learning resource they have at their disposal…[and]...differences in using time create inequities in opportunity to learn” (pp. 29-30). The system, then, perpetuates the use (or misuse) of this precious and limited commodity; a radical shift in thinking will need to occur in order to press for allocations of time for SDL activities and processes. 

이러한 주장을 할 때 '단순히 시간을 더 달라'라고 주장하는 것이 아님을 강조하는 것이 중요하다. 그보다 Goodlad의 말을 활용하자면, "우리는 시간을 더 달라고 주장하는 것을 멈추어서는 안된다. 나는 언제나 많은 시간을 무익하게 쓰느니 적은 시간을 잘 사용하는 것을 선택해왔다. 시간을 늘리는 것은, 사실상, 어떻게 그 시간을 사용할 것인가에 대한 개선이 동시에 있지 않다면 오히려 생산성을 저해시킬 뿐이다."

It is important, when making such arguments, to underscore that we are not arguing for simply more time but echo the sentiments of Goodlad (1984), who states: We must not stop with providing only time. I would always choose fewer hours well-used over more hours of engagement with sterile activities. Increasing [time] will, in fact, be counterproductive unless there is, simultaneously, marked improvement in how time is used. (p. 283)

전략 9: 대화 학습법을 핵심 방법으로 강조하기

Strategy 9: Emphasize Dialogical Learning as a Core Method

대화의 힘이 고관여의 심화학습의 줏추돌임은 이미 보여진 바 있다. Armitage는 이렇게 주장했다. 대화는 학생과 교사가 아는 것과 다시 아는 활동을 통해 서로 모아준다. 교사에게 고정되어있던 지식을 정적으로 전달하는 것 대신, 대화는 의식화 운동(conscientization)의 과정을 통해 지식을 칠천할 것을 요구하며 재생산한다.

The demonstrated power of dialogue as the cornerstone for engaged and deep learning seems clear. Armitage (2013) asserts: ...Dialogue brings together the teacher and the student in the joint act of knowing and re-knowing the object of study, where instead of transferring knowledge statically, as a fixed possession of the teacher, it demands and recreates acts of knowledge through the process of conscientization. (p. 7)

현재의 정보통신기술을 활용하여 실시간이 아니어도 학습자는 토론을 할 수 있다.

Rather, harnessing current information and communication technology tools (e.g., smart phones), learners would be able to extend the discussion not only in real time,

전략 10: ICT를 사용하라

Strategy 10: Provide and Train Learners in the Use of Information And Communication Technologies (ICT) Tools to Enhance SDL Strategies

전략 11: 학습자가 정보를 관리하고 평가할 수 있게 하라.

Strategy 11: Help Learners to Manage and Evaluate Information

정보의 신빙성과 관련성을 평가하는 기술이 필요하다.

Honing these skills to include critical appraisal of the trustworthiness (of sources, validity, etc.) of relevant and targeted information resources will prepare medical students for the realities of being a physician in the 21st Century (Cronin et al., 2014).

전략 12: 교수개발이 필요하다

Strategy 12: Train Faculty in SDL

성공적인 SDL을 도입하려면 교수들의 참여가 필수적이다. 처음에는 약간의 긍정적인 평가에 지나지 않을 수 있다.

The most critical factor in the successful implementation of an innovation such as the integration of SDL across the medical curricula will be medical faculty buy-in, which, initially, may be little more than positive regard, or a general agreeableness to the idea.

SDL에 대한 아이디어가 도입되기 시작하면, 실험과 평가, 긍정적 평가를 통해서 근거를 제시해야 하고, 그 다음에는 기관 전체의 교수들에게 SDL전략의 설계, 전달, 평가에 대한 훈련을 통해 효과적인 도입이 가능하다.

Once the idea of SDL takes root, providing concrete evidence of its efficacy via trials, evaluations, positive assessments, etc., then broaching the next steps, namely, taking an integrated approach to SDL and moving well beyond buy-in from medical faculty to an institution-wide commitment to training in the design, delivery and evaluation of SDL strategies will ensure effective implementation.

It is important to underscore that many of the SDL learning strategies described above, especially those that are skills, knowledge, attitudes-based, are not mutually exclusive; it is likely that these would be used in an ever-changing constellations or combinations, when needed and as the particular SDL challenges dictate. The point here is that the medical student uses what she needs, when she needs it; and applies these in the ways she needs to, to direct and be in control of her own learning.

It is clear that not all of the suggestions provided above could immediately, or easily be adopted and integrated by any particular medical education faculty and curriculum. However, moving the established medical education system toward a greater emphasis on self-directed learning principles and practices, even if incrementally, would be a step in the right direction and yield positive results as we prepare the doctors of tomorrow for lifelong learning.

Grow, G. O. (1991/1996). Teaching learners to be self-directed. Adult Education Quarterly, 41 (3), 125-149. Expanded version available online at: http://www.longleaf.net/ggrow

---

PRACTICAL STRATEGIES TO PROMOTE SELF-DIRECTED LEARNING IN THE MEDICAL CURRICULUM

Dirk Morrison and Kalyani Premkumar

Ideally, the 21st century physician, as a lifelong learner, is empowered by a deep understanding and actualized skills of self-directed learning (SDL). While SDL is an intuitively valued element of most medical education curricula, unless SDL is explicitly valued and spirally integrated across the curriculum, it is unlikely to be acquired as a core learning skill set by undergraduate medical students. In this paper, we outline a coherent set of practical strategies to promote and sustain SDL in the undergraduate curriculum. The implementation of these teaching and learning strategies may reverse a trend discovered in one medical school (i.e., a drop in student SDL readiness), by providing a teaching and learning environment in which the principles of SDL can be fully supported and actualized.