학부의 CBME에서 학생의 지식습득/임상수행능력/진료준비도인식의 차이: 비교 연구(BMC Med Educ. 2013)

학부의 CBME에서 학생의 지식습득/임상수행능력/진료준비도인식의 차이: 비교 연구(BMC Med Educ. 2013)

The effect of implementing undergraduate competency-based medical education on students’ knowledge acquisition, clinical performance and perceived preparedness for practice: a comparative study

Wouter Kerdijk1*, Jos W Snoek2, Elisabeth A van Hell2 and Janke Cohen-Schotanus1

Background

현대 의학에서 의사의 역할에 대한 사회적 우려에 대하여, CBME는 점차 전 세계적인 관심을 받고 있다. 여기에 깔린 전제는 BME가 의료에 더 잘 준비된 의사를 만들 것이라는 기대이다.

In response to societal concerns about the role of doctors in contemporary healthcare, competency-based medical education is receiving increasing attention worldwide [1-9]. Its underlying assumption is that competency-based medical education results in doctors who are better prepared for medical practice [10].

• 캐나다와 미국 PGME 프로그램 In Canada and the United States, the national accreditation councils have implemented competency-based criteria for postgraduate medical education [1,11].
• 학부 CBME Additionally, a competency framework has been proposed and guidelines have been developed for undergraduate competency-based medical education [5,12,13].
• EU, 볼로냐 프로세서의 일부로서 모든 의과대학 학부 교육과정은 명확하게 정의된 역량에 기반해야 함.
  In the European Union, as part of the Bologna process, all medical schools are required to base their undergraduate curricula on a clear and well-defined set of competencies [14].

 

CB교육과정의 주된 관점은 학생의 역량 개발을 촉진하는 것이며, 지식/술기/전문직적 자세로 구성된 능력을 보여줄 수 있게 하는 것이다. 그 결과 CBME를 도입할 때, 학생들의 역량개발competency development를 위한 교육시간을 따로 잡아놓게 된다. 이는 기존 교육과정을 가르칠 시간이 줄어든다는 것을 의미하고, 따라서 그러한 시간의 재분배가 역량개발을 촉진하는 결과와 더불어 다른 분야에서의 학생의 발전에 손상을 줄 수 있다.

A major focus of competency- based curricula is to facilitate students’ development of competencies, demonstrable abilities consisting of know- ledge, skills and professional behaviour. Consequently, when implementing competency-based medical education, curriculum time has to be reserved for students’ compe- tency development [2,15]. This means there will be less time available for existing activities of preceding curricula. Therefore, such a reallocation of time may not only result in the facilitation of competency development but may also impair students’ development in other areas.

CBAL과 AL 교육과정을 비교함(지식 습득, 임상 수행, 진료준비도인식)

Therefore, we examined undergraduate medical students’ knowledge acquisition, clinical perform- ance and perceived preparedness for medical practice for – two curricula a competency-based active learning (CBAL) curriculum and its predecessor, a regular active learning (AL) curriculum.

학부 교육과증은 정해진 기간이 있다. CBME를 도입할 때, 학생들이 역량을 개발시킬 수 있는 시간을 따로 잡아놓게 된다 역량개발을 목적으로 하는 여러 활동에 쓰이는 시간은 결국 예전에 지식 습득에 쓰였던 시간을 비용으로 하게 된다. 이러한 시간의 재배분은 학생의 지식습득에 안좋은 방향으로 영향을 줄 수 있다. 비록 학생의 지식이 임상수행능력의 즉각적 예측인자는 아니지만 간접적으로 임상수행능력에 영향을 줄 수 있다.

Undergraduate medical curricula usually have a set duration. When implementing competency-based educa- tion, curriculum time has to be reserved so students can develop their competencies. The time reserved for activ- ities aimed at competency development will usually come at the expense of time previously reserved for knowledge acquisition [15]. This reallocation of time may negatively affect students’ knowledge acquisition in a competency-based curriculum. Although medical stu- dents’ knowledge has not been found to be an immedi- ate predictor of clinical performance, it does impact clinical performance indirectly [16].

CBME를 이끄는 한 가지 힘은 대중들이 의과대학 교육과정이 현대의 진료와 관련된 needs를 반영하기 원하는 것이다.

One of the key forces behind competency-based medical education is the public call for medical curricula to reflect the needs of contemporary medical practice [1,15,17,18].

CBME에 걸쳐서 여러 역량과 그것들의 진료행위와의 관련성이 지속적으로 강조되며, 학생들은 의과대학 기간에, 그리고 나중에 진료를 할 때 무엇이 그들에게 기대되는가를 이해하게 된다.

Throughout competency-based curricula, relevant competencies and their relation with practice are continuously emphasized which helps students to under- stand what is expected of them during medical training and in medical practice [3,12].

Methods

맥락

Context

University of Groningen에서 수행

The AL and the CBAL curriculum were developed and implemented at the University of Groningen,

CBAL은 2003년 9월 도입, 7개 역량에 촛점

The CBAL curriculum was implemented in September 2003 and focuses on seven areas of competence:

• communication,
• clinical problem-solving,
• using basic knowledge and science,
• patient investigation,
• patient man- agement,
• social and community contexts of health care and
• reflection [22]. 

CBAL과 AL모두에서 active learning principles 이 적용되었다. 학생들은 지식을 소그룹에서 배우고, 동료들과 협동하면서 자기주도학습을 한다. 교사와 튜터는 코칭과 촉진자 역할을 한다.

In both curricula, active learning principles are applied to facilitate acquisition. Students learn in knowledge small groups, collaborate with their peers and engage in self-directed learning. Teachers and tutors fulfil a coaching and facilitating role [23].

학습법과 스킬 훈련에 배정된 시간은 비슷하다. 5주의 스킬훈련이 5주 임상실습 로테이션과 번갈아가면서 있다. 이러한 alteration의 목적은 학생들에게 딱 필요한 시기에 스킬을 개발하게 하고, 실제로 활용할 수 있게 하고, 지식 및 전문가적 태도와 통합시킬 수 있게 함으로써 전임상 과정에서 임상과정으로의 이행을 부드럽게 하기 위함이다.

Learning methods and the amount of time reserved for skills training are similar in both curricula. During this year, five-week periods of skills training in the clin- ical training centre are alternated with five-week clerk- ship rotations. The purpose of this alternation is to ease the transition from the preclinical to the clinical phase by helping students develop their skills, just in time, to apply them in practice and to further integrate them with knowledge and professional behaviour [24].

두 교육과정의 주된 차이는 역량개발competency development의 강조에 있다. CBAL에서는 과목 내내 각 과목과 역량과의 관련성을 명확히 소통하며, 15%의 CBAL 교육과정의 시간은 역량개발을 위한 소그룹 세션으로 배정되어 있다. 이 세션의 시간은 원래 AL에서 지식습득에 배정되어 있던 소그룹 세션을 없애서 만들었다. 총 시간은 동일.

The main difference between the two curricula lies in the emphasis on competency development. In the CBAL curriculum, the link between the purpose of each course and relevant competencies are clearly communicated throughout the course. This is not the case in the AL curriculum. Furthermore, 15% of the total CBAL cur- riculum time is reserved specifically for small group ses- sions aimed at competency development. Time for these sessions is created by diminishing the number of small group sessions originally aimed at knowledge acquisition in the AL curriculum. The total curriculum time re- mains the same.

CBAL의 전임상 시기동안 역량개발을 위한 소그룹세션은 학생들이 practice 경험과 그 영량과 관련된 영역의 과제를 바탕으로 이뤄진다.

Throughout the preclinical phase of the CBAL cur- riculum, small group sessions for competency develop- ment are based on students’ experiences in practice and assignments related to each area of competence. An ex- ample of such an assignment is that

• 1학년: 좋은 의사란?
  first-year students, unfamiliar with medical practice, have to describe the qualities of a good doctor.
• 3학년: 동일 과제를 반복하면서 그동안 무엇을 배우고 경험했는지 성찰
  In their third study year the students have to repeat this assignment, and reflect on what they have learnt and experienced in the meantime.

임상교육시기에 역량개발 세션은 1년에 24회. 이 세션에서 자신의 경험을 토론하고 자신의 개발과 관련된 특정 주제를 이야기함. 추가로 포트폴리오에 자기개발플랜 personal development plan 을 꾸준히 기록하고 여기에는 학습목표를 설정한다. 시니어 교수와 1년에 2회 포트폴리오를 바탕으로 면담하여 평가

During the clinical phase, sessions aimed at compe- tency development are scheduled 24 times a year. During these sessions students discuss their own experi- ences and certain themes in relation to their develop- ment (for example cultural diversity or dealing with death). In addition to assignments related to these meet- ings, students have to keep track of a personal develop- ment plan in their portfolio in which they formulate learning goals based on the areas of competence. During the clinical phase the portfolio is evaluated twice a year in an interview with a senior staff member.

CBAL 교육과정을 설계할 때 임상실습의 목적을 최대한 다양한 임상과를 경험하는 것으로부터 학생의 역량개발을 도울 수 있는 다양하고 안정적 환경의 균형을 맞추는 쪽으로 옮겨갔다. 그 결과 최소 로테이션이 4주로 늘어남. 

When designing the CBAL curriculum we felt that the aim of clerkships shifted from experiencing as many disciplines as possible towards a balance between diversity and the stability of surroundings to support students’ competency develop- ment. Consequently, in the CBAL curriculum, the mini- mum duration for clerkship rotations was extended to 4 weeks to allow sufficient time for students to work on their competencies.

Participants

Ethical statement

도구

Instruments

두 개의 다른 네덜란드 의과대학과 함께 치르는 interuniversity progress test (IPT) 로 평가. 1년에 4회, 6년간 총 24회. Dutch National Blueprint for the Medical Curriculum에 기반하여 출제되며 평가 목적은  “the end objectives of undergraduate medical training as far as knowledge is concerned” . 200개 객관식 문항. 특정 의과대학의 교육과정과 관련된 시험 아님. 이 연구가 이뤄질 당시, 네덜란드 의과대학 입학은 여전히 추첨 시스템으로 결정되고 있었기 때문에 교육과정의 효과를 비교하기에 유용함. 이 추천 시스템은 의과대학마다 1학년 입학생의 그룹이 매우 비슷해지는 결과(학업성취, 연령, 성별, 입학동기 등)을 가져왔음.

Knowledge acquisition was assessed by benchmarking our cohorts’ scores on the Dutch interuniversity progress test (IPT) against those of parallel cohorts from two other Dutch medical schools with similar cohort sizes (approximately 250 students per cohort). All cohorts sat the IPT four times per year at the same time, i.e. 24 tests per cohort. The IPT is based on the Dutch National Blueprint for the Medical Curriculum, and is designed to asses “the end objectives of undergraduate medical training as far as knowledge is concerned” [29,30]. Each progress test contains 200 multiple choice questions and is constructed to reflect the entire domain of medical knowledge. The IPT is not related to the cur- riculum of one particular institution [30]. The reason for benchmarking against two other medical schools was that all students sat exactly the same tests at the same point in their education. IPT benchmarking is especially suitable for analysing effects of curriculum changes be- cause, at the time of our study, admittance to medical schools in the Netherlands was still primarily deter- mined by a national lottery system [31]. This system guarantees an intake of first-year students which is very similar across medical schools with regard to past per- formance, age, gender and motivation to study medicine [32]. Over the period of our study the medical schools used for comparison had not changed their curricula.

 

 

Analysis

A Bonferroni correction was used to compensate for the high number of tests and effect sizes were calculated.

 

Results

Knowledge acquisition

Clinical performance

Perceived preparedness for medical practice

 

 

 

 

 

고찰

Discussion

 

연구의 목적은 CBAL의 도입의 효과를 보는 것이다. IPT결과에 따라 우리는 상대적으로 1학년에서 지식 습득이 떨어짐을 발견했다. 그러나 최종 졸업생에서 차이는 없었다. CBAL 교육과정 졸업생은 임상수행능력과 진료준비도인식에서도 차이가 없었다.

The aim of our study was to analyse the effects of the implementation of a competency-based active learning curriculum (CBAL) as compared to the previous active learning curriculum (AL). Using progress test results, we found relatively less knowledge acquisition in the first years of the CBAL curriculum than in the first years of the AL curriculum. However, we did not find such dif- ference in the final year. Graduates who had been trained in a CBAL curriculum did not score higher on clinical performance nor did they feel better prepared for medical practice.

역량개발에 시간이 더 들어갈수록, 다른 교육활동에 시간이 덜 들어가고, 그 결과 CBAL 교육과정은 지식 손실의 위험이 있다.

As more time is allocated to the development of competencies, less time will be devoted to other curricular activities. As a consequence, implementing a CBAL cur- riculum bears the risk of knowledge loss.

지식습득에 대한 시간을 빼서 역량개발을 위한 시간을 따로 두는 것은 (장기적으로는 아니나) 단기적으로는 낮은 지식습득의 결과로 이어졌다.

Reserv- ing time for competency development at the expense of time reserved for knowledge acquisition, seems to lead to lower knowledge acquisition in the short term, but not in the long term.

CBAL학생군이 종종 더 낮은 점수를 받았으나, 장기적으로는 차이가 없었다는 결과로부터, CBME가 영속적인 부정적 효과가 있을 가능성은 낮다고 판단된다. 이러한 결과는 임상환경이 학생이 스스로 학습을 조절regulate하게 장려했다는 것으로 설명될 수 있다. 임상실습동안 학생들은 반복적으로 부족한 의학지식 영역에 대한 remedy를 하게끔 stimulate된다. 이전 지식의 부족은 임상실습기간에 극복될 수 있다.

As the CBAL cohorts seldom scored lower than the comparison cohorts and no long-term differences were found, we consider a permanent negative impact of implementing competency-based education on student learning and expertise development unlikely. An explan- ation for this finding might be that the clinical environ- ment encourages students to regulate their own learning [37]. During clerkships students are repeatedly stimu- lated to remedy deficiencies in medical knowledge. Undergraduate students’ prior knowledge deficiencies appear to be overcome during their clerkships.

우리는 CBAL학생이 임상에서 더 잘할 것을 기대했으나, 유의한 차이는 발견하지 못했다.

We expected CBAL students to perform better in clin- ical practice than AL students. However, we did not find a significant difference, which may indicate that imple- mentation of competency-based education has no effect on clinical performance.

우리는 CBAL학생이 진료에 더 잘 준비되었다고 느끼길 바랐으나, 'put a patient problem in a broad context of political, sociological, cul- tural and economic factors, '에서만 그렇게 응답하였다.

We expected the CBAL students to feel better pre- pared for medical practice. Students from the CBAL curriculum felt better prepared to put a patient problem in a broad context of political, sociological, cul- tural and economic factors, which is in line with the aim to educate medical professionals who are sufficiently re- sponsive to societal needs [1,15,17,18]. However, we were unable to demonstrate any other effects of the implementation of competency- based education on students’ perceived preparedness.

학생들의 진료준비도인식에 전반적인 향상이 없었던 것은 역량개발을 위하여 도입한 교육도구(포트폴리오와 역량 및 underlying framework에 대한 명쾌한 의사소통)의 영향일 수 있다.

The fact that we did not find a general increase in stu- dent’s perceived preparedness for medical practice may be related to the educational tools we implemented to facilitate competency development: portfolio use and ex- plicit communication of competencies and their under- lying framework.

Sargeant 등에 의한 최근 연구에서 역량에 대한 명쾌한explicit 의사소통과 포트폴리오 활용이 학생들이 informed self-assessent를 하게 도와준다고 하였다. CBAL교육과정 학생들은 그들에게 기대되는 바가 무엇이에 대한 정보를 계속 알 수 있었고, 스스로의 수행능력을 explicitly 성찰하고, 부족한 부분을 보충remedy하고 개선점을 찾도록 하였다. 이러한 활동으로 인해서 학생들은 스스로의 부족함을 더 인식하게 되었을 것이다. 아마도 CBAL학생들은 AL학생보다 자신의 역량이 무엇이 있고 무엇이 부족한지 더 잘 인식하고 있었을 것이며, 역량개발에 있어서 이는 중요한 단계이다.

A recent study by Sargeant et al. revealed that explicit communication of competencies and the use of portfolios help students to achieve in- formed self-assessment [39]. Students in the CBAL cur- riculum are frequently informed of what is expected of them and they are explicitly stimulated to reflect on their performance, to remedy their deficiencies and to formulate points of improvement. The awareness that follows from these activities may help students to be- come increasingly conscious of their deficiencies. Possibly, CBAL students were more aware of their com- petencies and incompetencies than AL students, which is an important step in the development of competence [40].

 

 

 

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BMC Med Educ. 2013 May 27;13:76. doi: 10.1186/1472-6920-13-76.

The effect of implementing undergraduate competency-based medical education on students' knowledgeacquisition, clinical performance and perceived preparedness for practice: a comparative study.

Kerdijk W1, Snoek JW, van Hell EA, Cohen-Schotanus J.

Author information

• 1Center for Research and Innovation in Medical Education, University of Groningen and University Medical Center Groningen, Ant, Deusinglaan 1, FC40, 9713 AV, Groningen, The Netherlands. w.kerdijk@umcg.nl

Abstract

BACKGROUND:

Little is known about the gains and losses associated with the implementation of undergraduate competency-based medicaleducation. Therefore, we compared knowledge acquisition, clinical performance and perceived preparedness for practice of students from acompetency-based active learning (CBAL) curriculum and a prior active learning (AL) curriculum.

METHODS:

We included two cohorts of both the AL curriculum (n=453) and the CBAL curriculum (n=372). Knowledge acquisition was determined by benchmarking each cohort on 24 interuniversity progress tests against parallel cohorts of two other medical schools. Differences in knowledgeacquisition were determined comparing the number of times CBAL and AL cohorts scored significantly higher or lower on progress tests. Clinicalperformance was operationalized as students' mean clerkship grade. Perceived preparedness for practice was assessed using a survey.

RESULTS:

The CBAL cohorts demonstrated relatively lower knowledge acquisition than the AL cohorts during the first study years, but not at the end of their studies. We found no significant differences in clinical performance. Concerning perceived preparedness for practice we found no significant differences except that students from the CBAL curriculum felt better prepared for 'putting a patient problem in a broad context of political, sociological, cultural and economic factors' than students from the AL curriculum.

CONCLUSIONS:

Our data do not support the assumption that competency-based education results in graduates who are better prepared for medicalpractice. More research is needed before we can draw generalizable conclusions on the potential of undergraduate competency-based medicaleducation.

PMID:

 

23711403

 

[PubMed - indexed for MEDLINE] 

PMCID:

 

PMC3668236

 

Free PMC Article