성인학습이론과 의학교육: 리뷰 (Malta Med J, 2009) ◎

성인학습이론과 의학교육: 리뷰 (Malta Med J, 2009)

Adult learning theories and medical education: a review

Jürgen Abela

Introduction

과거에는 해당 주제를 아주 잘 알면 그것을 가르칠 수 있다는 생각이 있었다. 그러나 의료행위의 복잡성으로 인해서 UME와 PGME에서 그 복잡성을 적절히 다룰 수 있는 교육전략이 필요하게 되었다. 실제로 교수들에게 교육 기술을 가르치는 것은 더 나은 학습성과로 나타난다.

In the past, there has been an assumption that if a person knows very well the subject, then, he will be able to teach it. However the complexity involved in practising medicine must be tackled with appropriate educational strategies in the training and education of undergraduate and postgraduate students. In fact, training teachers in educational techniques translates in better student learning outcomes.1

성인학습이론

Adult learning theories

대부분의 교육이 이뤄지는 의학의 맥락에는 '성인'이 포함되며, 따라서 성인학습이론에 초점을 맞추는 것이 논리적이다. 여기에는 도구적 학습, 자기주도 학습....등등이 포함된다. 이 중에서 자기주도학습은 학습자 개개인에 초점을 맞추며, 자기주도 이론은 성인학습에 초점을 둔다.

Given that in the medical context most education involves adults, it is logical to focus on adult learning theories. There are many adult learning theories, which can be grouped into five main classes. These include Instrumental learning, self-directed learning, experiential learning, perspective transformation and situated cognition.2 Of these, self-directed learning particularly focuses on the individual learner as primary focus. Prominent amongst these self-directed theories is andragogy.

'성인학습'이라는 용어는 1833년 Alexander Kapp에 의해서 그리스 철하자 플라토의 이론을 설명하기 위해 처음 사용되었다. 그는 continuing education에서 성인이 참여하게되는 일반적 과정을 표현하고자 했다. 20세기에 존 듀이, 에듀어드 린데만, 마타 앤더슨 등은 성인학습이론을 추구하였으나 미국에서는 대체로 관심을 받지 못했다. 1980년대에 상황이 변하면서 Malcolm Knowles가 지지하면서 개념을 더 정교화했다.

The term andragogy (andra – meaning “man”; agogos – meaning “learning”) was first used by Alexander Kapp in 1833 to describe the educational theory of the Greek philosopher Plato. He used it to refer to the normal process by which adults engage in continuing education. In the 20th century, various respected intellectuals, such as John Dewey, Eduard Lindeman, and Martha Anderson pursued theories of andragogy, but were largely ignored in the US. Things changes in the 1980’s, with the work of Malcolm Knowles who championed this theory and further elaborated the concept.3

성인학습은 성인에 대해서 다음을 가정한다.

Andragogy assumes that adults: 

• are independent and self directing, 

• have (various degrees of) experience 

• integrate learning to the demand of their everyday life 

• are more interested in immediate problem centred approaches and 

• are motivated more by internal than external drives.

다른 특징은 성인학습환경과 관련되었는데, 이는 교수자와 학습자의 상호존중, 그리고 학습자간의 상호존중이 중요하다. 존중은 안전한 학습환경의 촉매이기에 중요하다.

Another characteristic deemed to be relevant to adult learning environments, is the importance of mutual respect between teacher and learner and also amongst the learners themselves. Respect is important since it is a catalyst for a safe educational environment.4

안타깝게도, 성찰(reflection)은 성인학습의 중요한 요소임에도 Knowles의 성인학습 개념에서 배제되어 있다. 사실 '성찰'은 Kolb의 학습사이클에서 네 단계 중 두 번째 단계이다. 이에 더하여 성찰은 성인학습과 아동학습의 중요한 차이점이다. 또한 성찰은 성인학습에서 학습동기를 향상시키는 역할을 한다.

Unfortunately, reflection is left out of Knowles’ concept of adult learning, despite being an important component of adult learning skills.5,6 In fact, reflection is the second of the four steps in Kolb’s Learning Cycle.7 In addition, the importance of reflection can be appreciated even more when one considers it to be an important difference between adult learning (andragogy) and child learning (pedagogy) theories. Finally, reflection can be seen to enhance adult learning by increasing motivation to learn.8

동기부여는 성인학습을 쌓아나가는 또 다른 중요한 기둥이다. 동기부여에 대한 이론 중에는 두 가지 주요 그룹이 있다.

Motivation is another important pillar on which adult learning is built. There are two major groups of theories describing motivation: 

• 내용 이론: 무엇이 사람들에게 동기를 부여하는가  content theories: these describe what motivates people, and 

• 절차 이론: 어떻게 사람들이 동기부여되는가 process theories: these describe how people are motivated.9

내용 이론중 가장 유명한 것 중 하나는 Maslow의 욕구위계이론이다.

One of the most popular of the content theories is Maslow’s Hierarchy of Needs.10

그러나 Maslow의 모델은 너무 경직되어 있다. 또한 개개인은 학습 궤적동안 만족하면서 불만족할 수 있다. 따라서 이는 부적절하게 보일 수 있다. 더 매력적인 내용이론은 ERG이다.

However, Maslow’s model may be seen to be too rigid. In addition, an individual may be satisfied and unsatisfied with various needs simultaneously throughout his learning trajectory. It can thus be seen to be inadequate. A more appealing content theory is the one put forward by Clayton Alderfer, who describes and summarises motivation in three needs, ERG:9 

• 존재 Existence – this is more or less equivalent to Maslow’s safety and physical well being steps 

• 관계 Relatedness – stresses the importance of interpersonal and social relationships 

• 성장 Growth – intrinsic individual desire for personal growth

절차이론은 특정 행동은 특정 자극에 의해서 발생한다는 생각에 기초한다. 이러한 것 중하나는 기대이론(Expectancy Theory)이다.

Process theories of motivation, on the other hand, are based on the idea that certain behaviours are produced by particular stimuli. One such theory is the Expectancy Theory which states that motivation depends on two perceptions:11 

1. 성과가 기대한 보상을 가져올 것이다.

2. 요구되는 행동을 수행할 능력이 그 사람 안에 있다.

1. an expectation that an outcome will bring the desired rewards 

2. the required performance is within the capability of the person.

성인학습에서 Knowles는 성인학습자는 본질적으로 내적동기를 부여한다고 기술했다. 그는 외적동기를 기술하지 않았으며, 특히 주된 동기부여의 원천으로 교사의 역할을 기술하지 않았다. 실제로 Peyton은 대부분의 성인학습자가 효과적인 학습을 하기 위해서는 교사에 의해서 부여되는 동기가 필요하다고 지적했다.

In andragogy, Knowles states that adult learners are self (intrinsically) motivated.3 He fails to mention extrinsic motivation and especially, the role of the teacher as major source of motivation. In fact, as Peyton9 points out, most adult learners require the motivation provided by teachers for effective learning to take place.

모든 성인학습이 동등하게 내적동기부여가 되는 것은 아니며, 이는 성인학습이론이 동기부여에 관해서는 부적절할 수 있음을 보여준다. 실제로 교수-주도 학습에서 학생-주도 학습까지 다양한 학습전략을 혼합할 필요가 있다. 이는 학습자와 교수자의 스타일이 맞춰져야 할 필요를 시사한다.

Not all adult learners are equally intrinsically motivated, and this further highlights the inadequacy of andragogy with respect to motivation. In fact, there necessarily arises the need of a mix of learning strategies, ranging from teacher-directed to student-directed learning.13 This implies that there needs to be a “match” (Figure 2) between the learner and the teaching styles used.14

분명히, 이는 교사가 어느 정도는 유연해야 함을 시사한다. 그러한 역학관계에 도달하기 위해 가장 중요한 것은 학생의 요구를 사정하는 것이며, 요구사정이 없는 교육은 진단 없는 치료와 다를 바 없다.

Certainly, this involves an amount of flexibility on the part of the teacher. The most important step to clinch such dynamic relationship is to carry out a needs-assessment of the student/ trainees involved. Without such needs assessment, teaching would be tantamount to treatment without a diagnosis.

예컨대 첫 번째 임상실습에서 학생은 교사가 어떻게 병력을 청취하는지를 봐야 하며, 이후 몇 년이 지나며 검진 기술에 대한 학습전략을 거쳐 몇달이 더 지나면 감별진단과 치료까지 논의할 수 있게 된다.

For example, whereas in the first clinical attachments, students would be dependent on the teacher to show them how to take a history, during the subsequent years, the learning strategies should deal with examination skills, going on further along the months to discussing the differential diagnosis and treatment of the patient’s symptoms.

이러한 역동적 과정은 다양한 도구를 통해 가능하다

This dynamic process can be successfully achieved with a variety of tools: 

• Reflective diary/practice – this will stimulate reflection and facilitate in-depth search on certain topics in addition to allowing for personal development.

• The relevance of what is being taught to medical practice should always act as a background for any discussion on topics.

• Use of the trainees’ experiences to discuss issues in practice, especially at postgraduate level. 

• Small group work on abstract or “difficult” concepts e.g. end of life. 

• Problem based learning. 

• Open discussions on “hot topics” such as medico-legal litigation.

성인학습이 적절히 '성찰'과 '동기부여'를 다루는데 실패했다고 할 때, Mezirow의 '전환학습'이론이 보다 적합해보인다. 이 이론의 핵심은 성인이 경험을 축적하고 이해해가는 메커니즘과 구조에 있다. 전환학습은 성인학습자가 사용하는 확립된 기준점으로부터 변화를 가져오는 것에 목적이 있다. "frame of reference"라 불리는 이것은 사람들이 경험에 대해서 의미를 찾기 위한 구조를 말한다. 따라서 이 FOR이 한 성인의 유전적 구성과 문화적 축적을 반영하는 것이 명확하다. 이 FOR은 다양한 과정을 통해서 변할 수 있는데, 주로 FOR을 구성하는 assumption에 대한 '비판적 성찰'을 통해서 변화한다.

Given that andragogy fails to adequately address reflection and motivation, Mezirow’s concept of Transformative Learning seems more appropriate.12 Crucial to this theory are the structures and mechanisms through which adults assimilate and understand their experiences. Transformative learning aims to effect change in established reference points used by the adult learner. These so called frames of reference are the meaning which people give to experiences and the structures used to arrive to such meaning. It is thus clear that these frames of reference are a reflection of the genetic make-up and cultural assimilation of the particular adult. These frames of reference can be transformed through a variety of ways, but primarily can be changed by critically reflecting on the assumptions which make up each frame of reference.

성인학습에서 교사가 동기부여의 역할을 한다는 점에서, 전환학습은 교사가 학습자에게 질문을 던지고, 자신과 타인의 assumption에 대해 성찰하는 것을 촉진해야 함을 강조한다. critical incident analysis, small group work 등의 방법이 있다.

In line with the motivating role of the teacher in adult learning, Transformative Learning stresses the importance of the teacher in facilitating learners to question and reflect on their own and others’ assumptions.12 Methods that may be particularly useful in this situation include critical incident analysis, small group work to formulate ideas on particular topics and reflective practice.

이러한 생각은 "The Inner Apprentice."와도 유사하다. Neighbour 가 1992년 주장한 이 개념은, 피훈련자의 학습과정을 묘사한다. Neighbour 는 The Inner Apprentice 라는 용어를 통해서 "정확한 정보가 정확한 장소에 정확한 시점에 제공될 때, 본질적으로 자기-교육 의 성격을 가지는 무의식적 학습기전"이라 설명했다. 우호적인 학습환경이 있다면 inner apprentice(피훈련자)는 kairos라는 단계를 거치면서 cognitive dissonance 에서 cognitive resonance로 나아가며 지식을 습득한다. 그리스어로 Kairos란 행동의 적절한 시점을 말하며, "Kairos"의 기간에 피훈련자는 가장 명확하게 문제의 핵심을 인식할 수 있고, 변화하는 정보를 가장 잘 받아들인다. mutative information은 FOR의 변화를 일으키고, cognitive resonance에 도달하게 한다.

It is very similar to and indeed complements the idea of The Inner Apprentice.16 This concept was put forward by Neighbour in 1992, to describe the learning process of trainees. Neighbour put forward this concept to highlight what he called The Inner Apprentice i.e. the unconscious learning mechanism that is intrinsically self-educating, provided the right information is provided in the right place and at the right time. Given such favourable learning climate, the inner apprentice (trainee) acquires knowledge (learns) by moving from cognitive dissonance to cognitive resonance through stages of “kairos.” Kairos in Greek means the right time of action, and by analogy, during points of “kairos” the trainee can most clearly recognise the nub of the issue and is most receptive to mutative information. This mutative information eventually leads to changes in the frames of reference to achieve cognitive resonance.

성인학습 이론을 살펴나갈 때, 그것이 의미하는 바가 무엇인지에 대해 길을 잃을 수 있다. 즉 성인학습을 촉진하고 효과적인 교육을 촉진하는 것이 무슨 의미인지 하는 것이다. 다른 말로는, 의학 영역에서 이는 의학역량의 성취를 말한다. 실제로 의학역량을 달성하는 것은 의학교육 상황에서 궁극적 동기부여요인이 되어야 한다. 이는 많은 경우 당연한 것으로 여겨지지만 실제로 의학교육에서 많은 경우 역량달성에 실패한다. 의학역량은 다음과 같이 정의된다.

Going through the theories of adult learning, one runs the risk of losing track of what they stand for – to enhance adult learning and facilitate effective teaching. In other words, in the medical field, this means the achievement of medical competence, whatever speciality, by the trainee. Indeed, achieving medical competence should be (and usually is) one of the ultimate motivations of any medical educational setup. This statement is many times taken for granted, but medical education, may at times actually lead to incompetence.17 Medical competence can be defined as: 

“The habitual and judicious use of communication, knowledge, technical skills, clinical reasoning, emotions, values and reflection in daily practice for the benefit of the individual and the community being served.”18

의학교육이 지식/술기/태도의 상호연관된 영역에 기반하고 있을 때 이는 이론적 개념을 실천할 때 타당하고 효과적인 적용이 필요함을 의미한다. 지식은 이렇게 정의된다.

This implies that there needs to be a sound and effective application in practice of theoretical concepts, using the fact that medical education is based on three interrelated domains, which are knowledge, skills and attitudes.19 Knowledge can be defined as: 

지식이란: “…a background of facts and interactions between facts that should lead to an understanding of the material being learned”20

지식의 결여는 종종 발견하기 어렵다. 지식에 관한 한 가지 흥미로운 묘사방법은 JoHari Window(JW)를 사용하는 것이다.(JoHari Windows (JW)put forward by Joseph Luft and Harry Ingham (hence: Joseph & Harry = JoHari))

Lack of knowledge is occasionally difficult to identify. An interesting way to picture knowledge (and the lack of it) in learners is by the using the concept of JoHari Windows (JW)put forward by Joseph Luft and Harry Ingham (hence: Joseph & Harry = JoHari)21. They developed this model in the 1950’s while working on group dynamics.

이 분류를 통해서 지식의 다양한 측면을 설명할 수 있다.

Through this categorisation, various aspects of knowledge can be addressed accordingly, though 

• 4영역: 다루기 어려움 area 4 (The Unknown area) is not amenable to modification. 
• 2영역: Blind Spot Thus area 2, is called the Blind Spot since it refers to knowledge not known to the trainee. This can be addressed through didactic-interactive type lecturing, where new information is provided. 
• 3영역: Facade Area Area 3 is called the Facade Area, and refers to what the person knows about himself which the rest of the people do not know. This can be tackled using discussions and small group work. 

Teaching of both areas 2 and 3, and possibly area 4 is augmented with reflective practice.

Skill은 마치 만병통치약처럼 여겨져왔다. 최근까지도 "시행하는 것을 한번 보고, 한번 직접 해보고, 다. 른 사람에게 한번 가르쳐 보라" 라는 말이 사용되었다. 이 방법은 skill의 다양한 측면, 예를 들면 무언가 잘 못 되었거나 부작용이 생겼을 때에 대한 추가적 탐색을 제한시킨다. 이에 더하여 의사소통과 같은 어떤 skill 은 이러한 형식에 들어맞지 않는다.

Skills are very much the panacea of medical institutions.Until recently the adage used to be “see one, do one, teach one.” This method fosters a sense of competition and pride in the medical profession but at the same time creates undue tension in the learner and also may inhibit exploration of various aspects of the studied skill for example when things go wrongs or possible complications which arise during or after the particular procedure. In addition, certain skills such as communication skills do not lend themselves readily to this format.

George와 Doto는 흥미로운 스킬-교육 프레임워크를 제시했다.

George & Doto offer an interesting skill-teaching framework:22 

1. 개요: 왜 이 스킬이 필요하며 어떻게 관련이 되는가. 스킬의 기본 개념 Overview: introduction to why the skill is needed and its relevance in the area of practice of the learner. Basic concepts on the skill. 

2. 코멘트 없이 보여주기 Demonstration without comment: allows the learner to observe a whole picture of required skill. 

3. 코멘트와 함께 보여주기(분절해서, 한 번에 다룰 수 있는 분량씩) Demonstration with comment: allows fragmentation of the skill into more manageable portions. 

4. 학습자가 skill을 구두 시연하기 Verbalisation: learner talks through the skill. 

5. 학습자가 skill을 실제 시연하기 Practice: the learner executes the skill.

마지막 단계에서는 긍정적 피드백과 격려를 해줄 수 있다.

In addition, it is felt that the final stage can be further supplemented by positive feedback and encouragement from the trainer.

George & Doto는 스킬 습득을 방해하는 요인도 기술하였다.

George & Doto go further and describe reasons which may prevent the acquisition of the required skill such as 

• inadequate demonstration/description, 
• imprinting of previous wrong exposures and 
• improper correction.

의학교육의 마지막 영역을 태도이다. 그러나 교육과정에서 적절한 수준의 인정을 받지 못하고 있다. 

The last domain in medical education is attitudes. In guidelines of desired medical conduct the attitudes of the medical professional are highly regarded.23 However, it is generally felt that in medical curricula this aspect is not given its due recognition. Through their own nature, attitudes are difficult to describe, quantify and address. Passing on desirable attitudes seems even more difficult.

다음과 같이 정의할 수 있다.

Attitudes can be defined as 

“…a learned predisposition to respond in a consistently favourable or unfavourable manner with respect to a given object.”19

'태도'를 교육할 수 있는 다양한 방법이 있다. 적절한 시나리오를 사용할 수 있다.

There are various ways in which attitudes can be addressed. In the undergraduate scenario, certain specialties, more than others, are useful in passing on particular attitudes. General practice and palliative care, for example, through their philosophies of holistic assessment and “total care” respectively, are suitable to pass on attitudes related to managing the patient and family.24,25 

실제로 "의학 수련과정에 완화의료를 포함시키는 것은 완화의료의 질을 향상시킬 뿐만 아니라 의사의 도덕적 수준 향상에도 기여한다"

In fact, “incorporating palliative care into medical training not only improves the quality of palliative care, but also contributes to the moral quality of the doctors being trained.”19

또 다른 방법은 임상환경에서의 OTJT(On the Job Teaching)이다. 지식와 술기 뿐 아니라 다양한 이슈에 대해서 토론할 기회가 된다.

Another relevant way of passing on appropriate attitudes is teaching in the clinical environment (also known as On the Job Teaching - OTJT). Together with providing an opportunity to pass on skills and even knowledge, OTJT offers an opportunity to discuss, albeit briefly, various issues which may crop up from different clinical scenarios.26 Such issues may include ethical questions and dealing with one’s own feelings when faced with a sick patient.

OTJT가 성공적이기 위해서는 교사의 계획과 헌신이 중요하다. 시간의 압박이 있을 경우에는 교육이 어려워질 수 있다.

For a successful OTJT experience, planning and commitment on behalf of the teacher is paramount. In addition, time pressures will certainly make things more difficult for teaching, especially during a busy ward round or outpatient session.

OTJT를 수행하는 다양한 방법이 있다.

There are various methodologies of carrying out OTJT which have been highlighted in a recent systematic review and are summarised in Table 1.27 

모든 상황에서 피드백은 Pendleton's rule을 따라야 하며 학생이나 피훈련자의 지위/평판(standing)을 훼손해서는 안된다.

Feedback, in such situations and indeed in all situations should be given along Pendleton’s’ rules, thereby not undermining the standing of the student or trainee.28

• first, the students says what went well, 
• followed by what the teacher thinks went well; then 
• the student talks about what could be improved and how, 
• followed by what the teacher thinks could be improved and how

Conclusion

However, the educational cycle is a useful concept for planning teaching activities. It consists of four steps:7 

1. Assessing the needs of the learner 

2. Setting educational objectives 

3. Choosing and using a variety of methods 

4. Assessing that learning occurred.

22. George JH, Doto FX. A simple five-step method for teaching clinical skills. Fam Med. 2001;33:577-8.

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Abstract

Adult learning theories describe ways in which adults assimilate knowledge, skills and attitudes. One popular theory is andragogy. This is analysed in detail in this review. The importance of extrinsic motivation and reflective practice in adult learning is highlighted, particularly since andragogy fails to address adequately these issues. Transformative Learning is put forward as an alternative concept. Using the three recognised domains of knowledge, skills and attitudes, ways of applying these theoretical concepts in medical education are subsequently discussed.