자기주도학습준비도와 의과대학에서의 지식기반- 혹은 수행능력기반- 척도로 측정한 성공의 관계(IJSDL, 2011)

자기주도학습준비도와 의과대학에서의 지식기반- 혹은 수행능력기반- 척도로 측정한 성공의 관계(IJSDL, 2011)

THE RELATIONSHIP OF SELF-DIRECTED LEARNING READINESS TO KNOWLEDGE-BASED AND PERFORMANCE BASED MEASURES OF SUCCESS IN MEDICAL STUDENTS

Brian W. Findley and Robert J. Bulik

Sloan, Donnelly, Schwartz, and Strodel은 "의사들은 임상역량이 지식만으로 충분하지 않다는 것을 안다. 충실한 지식의 토대를 갖추는 것은 필수적이지만, 임상 역량은 다른 숨낳은 영역도 포괄한다" 

Sloan, Donnelly, Schwartz, and Strodel (1995) declare, “Physicians recognize that clinical competence is determined by more than knowledge. Although a sound knowledge base is vital, clinical competence encompasses numerous other domains” (p. 736). Almost 20 years ago, 

• the UK Medical Council published Tomorrow’s Doctors, which called for increasing the SDL capacity in medical education (Whittle & Murdoch-Eaton, 2004). More recently, 
• the Accreditation Council for Graduate Medical Education (ACGME) established implementing practice-based learning in medical school as one of its six core competencies. Two of the key components of this approach are directly related to SDL--lifelong learning and self-reflection (ACGME, 2006).

문제의식

Problem Statement

의학교육의 중요한 교리 중 하나는 SDL과 같은 역량을 개발하여 평생학습, 독립적 학습을 할 수 있게 하는 것이다. Harvey, Rothman, and Fecker 는 "독립적인 자기주도적 평생학습자가 되게 하는 것은 학부의학교육의 중요한 목표 중 하나이다."라고 했다.

One of the major tenets of medical education is to cultivate competencies, such as SDL, that will transfer into lifelong, independent learning (Whittle & Murdoch-Eaton, 2001). Harvey, Rothman, and Fecker (2003) state that, “becoming an independent and self-directed lifelong learner is one of the critical outcomes of undergraduate medical education” (p. 1259).

의학과 3학년을 대상으로 한 연구에서 SDLRS/LPA가 일반인보다 매우 높은 평균점수를 받은 것이 나타났다.

Previously, a study done with third-year medical students enrolled in this curriculum curriculum (IMC) showed significantly (p < .01) higher mean scores (236.6) when compared to the general population (214.0) on Guglielmino’s (1978) Self-Directed Learning Readiness Scale/Learner Preference Assessment (SDLRS/LPA) (Bulik, 2003).

SDL에 의해서 의사로서 바람직한 자질을 기를 수 있기에, PBL/EBM은 의과대학 교육과정에 더 흔해지고 있다. 

Partially due to the fact that the desirable traits of physicians are fostered by SDL, PBL/EBM is becoming more common in medical school curricula. Therefore, the contribution of SDL throughout the medical school experience is worthy of investigation.

개념틀

Conceptual Framework

의과대학 통합교육과정

Integrated Medical Curriculum

AAMC에 따르면 의학교육과정의 질을 개선하는 것은 끊임없는 작업이다. 의학은 언제나 "진화하는 사회적 요구, 진료 패턴, 과학적 발전"에 응답해야 한다.

According to the Association of American Medical Colleges (1998) the process of improving the quality of medical education curriculum is continuous. Medicine must always be responsive to “evolving societal needs, practice patterns and scientific developments” (Association of American Medical Colleges, p. 9).

Lujan and DiCarlo 는 학부과학교육의 양이 학생들의 학업적 성공에 아무런 영향이 없음을 지적했다.

Lujan and DiCarlo (2006) note that the quantity of undergraduate science education has no effect on medical students’ academic success.

자연과학, 해부학, 생화학 지식이 거의 유지되지 않는 것 때문에 교육과정과 관련한 의사결정자들은 그들의 정책을 다시 생각해보게 되었다. 그 결과 "교사들은 학생이 암기해야 하는 사실정보의 총량을 줄이고, 수동적 강의 형태를 줄이고, 더 많은 시간을 학생들이 능동적, 독립적, 문제해결자가 되도록 하는데 노력해야 한다."라고 했다.

Low retention rates of basic science, anatomy and biochemistry information prior to medical school graduation have led those involved in curricular decision-making to rethink their strategies (Lujan & DiCarlo, 2006). As a consequence, the philosophy that “teachers should reduce the total amount of factual information students are expected to memorize, reduce our use of the passive lecture format, and devote much more effort to helping students become active, independent learners and problem solvers” (Lujan & DiCarlo, 2006, p. 17), is now prevalent in medical education. 

자기주도학습을 개발하기 위한 두 개의 비슷한 방법이 PBL과 EBM이다. 

Two closely related methods identified to facilitate the development of self- directed learning are problem-based learning (PBL), and evidence-based medicine (EBM) curricula (Williams, 2004). These forms of self-instruction have increased substantially over the past 15 years. In fact, 94% of medical schools reported using self-instruction in their curricula in 1998-99 (Albanese, 2000).

PBL의 도입

PBL, which is grounded in cognitive psychology, was introduced in the late 1970’s (Tärnvik, 2007) by Barrows and Tamblyn at McMaster University in Canada (Trevena, 2007).

PBL을 지적하는 사람도 있지만, 정보처리이론에 기반을 두고 있다.

While PBL has detractors (Colliver, 2000) who claim all medical education is clinically contextual, PBL is based on information-processing theory which involves activating prior knowledge, encoding specificity, and knowledge elaboration (Albanese, 2000; Schmidt, Vermeulen, & Van Der Molen, 2006).

EBM은 19세기 중반의 파리로 거슬러 올라가는데, 다음과 같이 정의된다. Bardley는 EBM이 진행되는 다섯 단계를 설명했다.

Evidence-based medicine, whose origins date back to mid-19th century Paris, is defined as “the conscientious, explicit, and judicious use of current best evidence in making decisions about the care of individual patients (Sackett, Rosenberg, Gray, Haynes, & Richardson, 1996, p. 71).” Bradley et al. (2005) identify five steps to the EBM process: 

• formulating clinically important questions, 
• efficient gathering of clinical evidence (research), 
• critical appraisal (assessment) of evidence, 
• applying evidence to practice, 
• evaluating own practice” (p. 150).

연구결과에 기반하자면 PBL.EBM의 인지적 장점은 SDL기술을 기르는 것이며, 이것은 다음에 도움이 된다.

Based on available research, the cognitive advantages of PBL/EBM are an increase in honing SDL skills that transfer to 

• professional practice, 
• motivation (Schmidt et al., 2006), 
• scientific thinking, 
• promoting deeper understanding (Yalcin et al., 2006), 
• better knowledge acquisition (Bradley et al., 2005; Schmidt et al.), 
• critical appraisal skills, learner autonomy (Bradley et al.), and 
• problem solving (Schmidt et al.; Yalcin et al.). 

대인관계적 장점은 다음과 같다.

The interpersonal advantages of PBL/EBM include 

• improved professional collaboration, (Schmidt et al., 2006; Yalcin et al., 2006), 
• conflict resolution (Yalcin et al.), 
• retention, 
• better patient communication, 
• teamwork, 
• expertise in running meetings, 
• helping colleagues’ confidence, 
• ability to work and plan efficiently (Schmidt et al.) and 
• improved attitudes (Bradley et al., 2005). Further, 

또한 전통적인 교육과정보다 장점도 있다.

PBL enhances enjoyment of school by both student and instructor when compared to traditional curriculum (Albanese, 2000), and they affiliate better, as well (Abraham, Upadbya, & Ramnarayan, 2005; Albanese, 2000). In fact, PBL graduates were more likely to, “spend more time in direct patient care, bill for more psychotherapy services per month, have an academic appointment, enter family medicine and be in group practice” (Albanese, p. 736).

의학분야에서의 자기주도학습

Self-Directed Learning in the Medical Field

세 개의 미국 의과대학에서 진행된 연구를 보면, SDLRS/LPA는 신뢰할 수 있는, 성-평등한 평가법이다. 의과대학생의 평균점수는 235점으로 일반 인구집단보다 높다.

In a study involving three U.S. medical schools (n=941), the SDLRS/LPA was found to be a reliable, gender-fair assessment. The mean score for the medical students was 235, placing them in the above-average range of SDLRS/LPA scores for the general population (Guglielmino, Mazmanian, Guglielmino, Hoban, & Pololi, 2002).

Assessments

Final grade.

National Board of Medical Examiners-Family Medicine Subject Examination.

Objective Structured Clinical Exam.

Preceptor ratings.

Self-Directed Learning Readiness Scale/Learning Preference Assessment.

Data Collection and Analysis

Findings

Mean Scores

연구질문 Research Question 1

Do medical students who have completed the FM clerkship have higher scores on the SDLRS/LPA than the general adult population reported by Guglielmino and Guglielmino in 1988 (214.0 + 25.59)? The mean SDLRS/LPA score was 229.06 + 23.19, which places the sample in the top 31% of those tested (Guglielmino & Guglielmino, 1991).

연구질문 Research Question 2

Is there a significant correlation between medical students’ SDLRS/LPA scores and knowledge-based measures of success (NBME scores)? The Pearson r correlation showed a significant (p < 0.05) relationship between SDLRS/LPA scores and NBME-FM scores, but the relationship was negligible (r = .073).

연구질문 Research Question 3

Is there a significant correlation between medical students’ SDLRS/LPA scores and performance-based measures of success (OSCE scores, preceptor rating scores)? The Pearson r correlation showed significant (p < 0.01) relationships between SDLRS/LPA and OSCE 1 (r = .109, p = .001), OSCE 2 (r = .103, p = .002), and OSCE AVG (r = .133, p = .000). Correlation analysis also showed significant (p < 0.05) correlations between SDLRS/LPA scores and preceptor rating 2 (r = .168, p = .034), and preceptor rating 3 (r = .305, p = 0.05).

연구질문 Research Question 4

Is there a significant correlation between medical students’ SDLRS/LPA scores and the combination of knowledge-based and performance-based measures of success (final grade)? Correlation analysis showed significant (p < 0.01) correlations between SDLRS/LPA scores and final grade (r = .138). While this correlation is significant, it should be interpreted with caution since the effect size is small.

연구질문 Research Question 5

Are knowledge-based and performance-based measures of success (OSCE and preceptor ratings scores) and SDLRS/LPA scores significant in predicting NBME-FM scores? Regression analysis was performed to determine the nature of the relationship between the variables. The regression equation used NBME-FM scores as the criterion variable and SDLRS/LPA scores, OSC AVG, and preceptor ratings as variables for predictors. The final grade was purposely not included in this analysis since NBME-FM scores were calculated into that score and it would confound the results due to collinearity.

Conclusions, Discussion And Recommendations

Conclusions and Discussion

While the relationships of SDLRS/LPA scores of medical students in this study with knowledge-based and performance-based examinations were modest, they mirror the relationships that have appeared consistently across a number of studies and indicate a tendency for medical students with higher levels of SDL to perform better in medical preparation programs.

One of the major tenets of medical education is to cultivate competencies, such as SDL, that will transfer into lifelong independent learning (Whittle & Murdoch-Eaton, 2001). Accordingly, Harvey et al. (2003) state that, “becoming an independent and self-directed lifelong learner is one of the critical outcomes of undergraduate medical education” (p. 1259). Bulik (2003) agrees, stating “Success in medical school is strongly related to the ability to direct and regulate one’s own learning experience” (p. 76).

새로운 지식이 끊임없이 생산되면서 진료의 표준을 준수하는 최신 상태를 유지하는 것은 의사의 직무 중 더욱 더 큰 부분을 차지하고 있다. 실제로 생의학지식의 반감기는 7~10년으로 추정되고 있다. Friedman 등에 따르면 생의학지식이 기하급수적으로 증가하고, 하나의 지식의 반감기가 짧아지면서 근대의학은 진료를 지원하고 에러를 줄이기 위해 점점 더 외부의 지식에 의존하게 되었다. 

The constant proliferation of new information has made maintaining currency with best practices for standards of care an even greater component of a physician’s job. In fact, it has been estimated that the half-life of biomedical knowledge is 7-10 years (Rugh, Goggins, & Hatch, 2009). According to Friedman et al. (2005), “the exponential growth of biomedical knowledge and shortening half-life of any single item of knowledge both suggest that modern medicine will increasingly depend on external knowledge to support practice and reduce errors” (p. 334). It is evident that physicians will be increasingly reliant on self-directed learning in order to maintain proper levels of care.

Albanese, M. (2000). Problem-based learning: Why curricula are likely to show little effect on knowledge and clinical skills. Medical Education, 34, 729-738.

---

THE RELATIONSHIP OF SELF-DIRECTED LEARNING READINESS TO KNOWLEDGE-BASED AND PERFORMANCEBASED MEASURES OF SUCCESS IN MEDICAL STUDENTS

Brian W. Findley and Robert J. Bulik

The purpose of this study was to compare the self-directed learning readiness of third-year medical students to the general population mean; and to determine (a) if relationships exist between selfdirected learning readiness and other measures of medical school success; and (b) if measures of success in medical school and Self-Directed Learning Readiness Scale (SDLRS/LPA) scores are significant in predicting National Board of Medical Examiners Family Medicine Subject Examination (NBME-FM) scores. Mean SDLRS/LPA score for the 873 participants was 229.06 + 23.19, significantly higher than the general population mean (p < .05). Correlations were significant for SDLRS/LPA scores to NBME-FM scores (r = .073, p < .05), Objective Structured Clinical Exam (OSCE) scores (r = .133, p < .01), and final grade (r = .138, p < .01). Regression analysis revealed that SDLRS/LPA, OSCE AVG and preceptor ratings predicted 9.7% of the variance in NBME-FM, which was significant (p < .001).