본다, 한다, 그리고는? PGME에서의 교수개발(Postgrad Med J. 2008)

본다, 한다, 그리고는? PGME에서의 교수개발(Postgrad Med J. 2008)

See one, do one, then what? Faculty development in postgraduate medical education

T Swanwick

과거에는 누구나 가르칠 수 있다고 생각했지만, 정말로 가르친다는 것이 우연에 맡겨도 되는 것인가? PGME는 변하고 있다. 의학교육의 전문화와 교육의 수월성을 추구하는 원동력이 임상교사의 높아져가는 책무성과 합해져서 stakes를 높이고 있다. 'Teaching the teachers' 혹은 교수개발은 더 이상 사치품이 아니며, 중요한 성과를 위한 핵심 활동이다.

In the past it was assumed that anyone could teach, but is this really something that should be left to chance? Postgraduate medical education is changing. A move to professionalise medical education and a drive for excellence in education, coupled with an increasing accountability of clinical teachers, is raising the stakes. ‘‘Teaching the teachers’’, or faculty development, is no longer an added luxury, but a core activity with impor- tant consequences.

교수개발은 무엇이며 왜 중요한가?

WHAT IS FACULTY DEVELOPMENT AND WHY IS IT IMPORTANT?

Steinert는 이렇게 말했다.

Steinert1 describes faculty development as:

‘‘…a planned program, or set of programs, designed to prepare institutions and faculty members for their various roles, with the goal of improving instructor’s knowledge and skills in the areas of teaching, research and adminis- tration’’

교수개발은 단순히 "가르치는 사람들에게 가르치는 방법을 가르치는 것'이 아니다. 이것은 clinical teacher의 교육활동을 전문화하기 위하여, 교육 인프라를 강화하기 위하여, 미래의 교육역량을 축적하기 위하여 추구하는 전 기관 차원의 활동이며, 다른 말로 하면 trainer와 trainee가 하는 일의 한중간에서 education clinician을 만드는 것이다. 교수개발이 "계획된 프로그램"이라는 측면이 특히 중요한데, 교수개발이 novice clinical teacher에게 입문 수준의 훈련을 제공하는 것 뿐만 아니라, 지속적인 ongoing professional development 의 기회가 되어야 한다.

Faculty development is more that just about ‘‘teaching the teachers to teach’’. It should be an institution-wide pursuit with the intent of profes- sionalising the educational activities of clinical teachers, enhancing educational infrastructure, and building educational capacity for the future—in other words, establishing education clinician and training at the centre of what trainers, and trainees, do. The ‘‘planned program’’ aspect of faculty development is particularly important, as not only should faculty development provide entry level training for novice clinical teachers, there must also be opportunities of ongoing professional development and support.

잘 훈련받은 의사가 더 환자진료를 잘 할 것이라는 것에는 핵심 가정이 있다.

 the belief that well trained doctors carry outbetter patient care holds a number of key assumptions, namely that: 

• 학습을 촉진하는 더 좋은/덜 좋은 방법이 존재한다. there are some good—and less good—ways to facilitate learning 

• 트레이너를 훈련시키는 것은 Trainee outcome을 향상시킬 것이다. training the trainers results in better trainee outcomes 

• 인적자원에 투자하는 것은 조직성과를 향상시킬 것이다. investing in human capital enhances organisa- tional outputs.

세 가지 형태의 교육이 의학교육을 지배해왔다. "연단의 현자", "대가 주위 배회", "핀잔주는 교육". 이 모두는 문제가 있다. 전통적인 강의 형식은 이미 40년 전부터 지식의 전이에 있어서 유용하지 못한 것poor vehicle으로 알려져 왔으며, 강의의 요점 중 42%만이 강의 직후에 기억나며, 이는 1주일 이내에는 20%, 이후에는 3~5%까지 낮아진다. 이 숫자에도 불구하고 PGME에서 강의는 여전히 주로 사용되는 방법이다.

Three forms of teaching have historically held sway in medical education: ‘‘the sage on the stage’’, ‘‘hanging around with the big boys’’ (also known as ‘‘learning by lurking’’), and ‘‘teaching by humiliation’’. All have their problems. The tradi- tional lecture format has been known for over 40 years to be a poor vehicle for the transfer of knowledge2 with only 42% of the key point of a lecture being recalled immediately afterwards, dropping to 20% within a week and to 3–5% thereafter. Despite these depressing figures, the lecture continues to be the staple diet of post- graduate education centres.

더 훌륭하고 나은 의사의 옆을 맴도는 것 만으로도 효과적인 학습이 가능할 수도 있으나, 이는 trainee가 (진료에) 기여하고 참여할 기회가 있을 때의 이야기이다. 시니어의 활동에 함께 할 수 있는 허가가 없이는 trainee는 수동적 관찰자의 역할 밖에 할 수 없으며, 학습경험이란 존재하지 않는다.

Simply being around bigger and better doctors may well be an effective way to learn, but only if the trainee is provided with opportunities to contribute and participate.3 Without permis- sion to join in with the activities of seniors, the trainee is confined to the role of passive spectator, and the learning experience is impoverished.

마지막으로, '핀잔주는 교육'은 - 회진에서 trainee를 박살내는 흔한 모습으로 - 비록 점차 사라질 것으로 기대되지만, professional development를 위한 자신감을 약화시키는 것으로 나타난 바 있다.

Finally, teaching by humiliation—the ritualistic dismantling of trainees on the ward round—though hopefully on the wane, has been shown to undermine the self confidence needed for the professional development of trainees and students.45

교수개발이 차이를 가져오는가?

DOES FACULTY DEVELOPMENT MAKE A DIFFERENCE?

Roop and Pangaro의 핵심 관찰 결과는, 학생이 인지적으로 가장 성장하게 해주는 사람은 주치의attending physician이 아니라 레지던트였다는 사실이다. 이것이 주는 중요한 함의는 교수개발이 단순히 consultant의 교육역량 강화에만 관련된 것이 아니며, 팀 전체의 역량강화와 관계된다는 사실이다

A further key finding of Roop and Pangaro10 was that it was the resident, rather than the attending physician, who made the most difference to the cognitive growth of students. This has an important implication—faculty development is not just about developing the educational competencies of consultants, but the whole team.

마지막으로, 교수개발이 중요한 이유는 기관 전체에 미치는 영향 때문이다. 이미 200년 전부터 인적자원에 투자하는 것은 조직에게 이롭다는 것이 알려져왔다.

Finally, faculty development is important because of its effect on the institution as a whole. Investing in human capital has been demonstrated to be beneficial to organisational output for over 200 years,

Senge는 다음과 같은 'learning organization'은 유연하고/적응력이 있으며/생산성이 높다고 하였다.

Senge has argued that learning organisations:

‘‘… where people continually expand their capacity to create the results they truly desire, where new and expansive patterns of thinking are nurtured, where collective aspiration is set free, and where people are continually learning to see the whole together’’13

are flexible, adaptive and productive.

 

 

 

왜 지금인가?

WHY NOW?

의학교육의 전문화

Professionalisation of medical education

영국에서는, 어느 정도는 Dearing report의 권고안 때문이나, 의과대학에 속한 의학교육학교실의 숫자가 늘어나고 있으며, 석사과정 프로그램과 postgraduate certificates가 늘어나고 있다.

In the UK, driven in part by recommendations of the Dearing report on the future of higher education15 (box 1), there has been a growth in the number of departments of medical education attached to medical schools, and a proliferation of masters level programmes and postgraduate certificates,16

 

 

(의학교육의) 책무성 증대

Increasing accountability

의학교육에서 이 책임은 다양한 방향에서 들어온다.

In medical education, this accountability is felt in a number of directions;

• 환자로부터 to the patient, through government agendas around ‘‘patient choice’’ and ‘‘patient safety’’;

• 피훈련자로부터 to the trainee as witnessed by the increasing importance laid on student evaluations, particularly in the USA, through to a growing number of appeals and legal challenges; and

• 규제기구로부터 to regulatory bodies, a role taken in the UK by the Postgraduate Medical Education and Training Board (PMETB).

수월성의 추구

Pursuit of ‘‘excellence’’

'수월성', '세계수준'과 같은 용어는 오늘날 영국에서 정치적 유행어political buzzwords이다.

‘‘Excellence’’ and ‘‘world classness’’ are the current political buzzwords in the UK public sector, cascading from the prime minister down.

 

 

어떤 유형의 교수개발?

WHAT SORT OF FACULTY DEVELOPMENT?

전형적인 내용

A typical content list is provided in box 2.24

교수개발 프로그램에 대한 최근의 systematic review에서는 교수개발 프로그램의 효과성에 기여하는 요인으로..

A recent systematic review looking at effectiveness of faculty programmes28 development found that the key features contributing to their effectiveness were:

• use of experiential learning 

• provision of feedback 

• effective peer/colleague relationships 

• well designed interventions following established educa- tional principles 

• use of a diversity of educational methods within single interventions.

PGME의 주요 특징

KEY FEATURES OF POSTGRADUATE MEDICAL EDUCATION

PGME는 UME와 많이 다르다.

Postgraduate medical education takes place in a very different environment.

근무지 기반 학습

Work based learning

 

Work based learning에서 최근 관심을 받기 시작한 몇 가지 영역

A number of areas of work based learning have roused interest in recent years.

• Eraut가 'non-formal learning'이라고 지칭한 것: 전문직과업 수행 중, 혹은 과업과 과업 사이에 발생하는 학습으로서 종종 학습자는 자신이 배운 것도 인식하지 못하기도 한다.
  The first of these is what Eraut30 31 terms non-formal learning—the learning that takes place during or between professional tasks, some- times even without the participant having been aware of what was learned.

• 도제식 모델로서 Master가 되기 위한 지식/술기/태도를 습득할 것으로 기대하며 직무에서 시간을 보내는 것. Lave and Wenger는 이러한 사회-문화적 발달을 ‘‘legitimate peripheral participation in a commu- nity of practice’’라고 지칭했다.
  Second is the apprentice model of education in which initiates spend time on the job in the hope that they will acquire the knowledge, skills and professional attitudes neces-sary to become a master.  Lave and Wenger32 famously characterised this socio-cultural progression from newcomer to old-timer as ‘‘legitimate peripheral participation in a commu- nity of practice’’, a process by which the novice learns to talk- the-talk and walk-the-walk.

• 마지막으로, interprofessional learning 이 있다. 진료의 퀄리티와 협력을 향상시키기 위해 둘 이상의 전문직이 함께, 서로로부터, 서로에 대해서 배우는 것
  Finally, there is an increasing focus on interprofessional learning in which ‘‘two or more professions learn with, from and about each other to improve collaboration and the quality of care’’.33

관리감독

Supervision

PGME의 상당부분은 동료간 전문적 대화의 결과로 이뤄진다.

A great deal of postgraduate education takes place as a result of professional conversations between colleagues.

이러한 '대화'를 가리키는 용어는 무척 다양한데, Launer는 "supervision"이라는 포괄적인 용어를 사용하였으며, 이것은 development 혹은 performance 혹은 둘 다에 초점을 둔 것으로, 대화의 맥락에 따라 달라진다

The terminology in this area is overlapping and frequently confused, though Launer has help- fully brought much of the literature together under the blanket term ‘‘supervision’’—a concept that may focus on development or performance or both, dependent on the context of the conversation.34

임상현장에서 이뤄지는 수행능력 평가

Performance assessment in clinical settings

점점 더 의료역량의 평가는 실제 근무환경에서의 수행능력을 평가한다. 평가근거 수집에서 질적 접근이 (기존의) "단일 시험 단일 특성 (평가)‘‘one-trait one-test’’ " 식 접근법을 대체하고 잇으며, (역량에 대한) 풍부한 그림을 삼각측량하여 쌓아가는 식으로 바뀌고 있어서 통제된 시험 환경에서가 아니라 실제 환자를 대상으로 하는 것을 평가한다.

Increasingly, assessments of medical competence now examine the actual performance of trainee doctors in their work setting. Qualitative approaches to the collection of assessment evidence are being adopted as the ‘‘one-trait one-test’’ approach is being replaced by the building of a triangulated rich picture over time, reflecting not just what doctors do (or say they will do) in a controlled examination situation, but what they actually do at work with real patients.36 37

환자 안전

Patient safety

PGME에서 teacher의 과제 중 하나는 교육기회를 최대화하면서 환자의 리스크는 최소화하는 것이다. 언제 take over하고 언제 let go 할 것인지를 아는 것이 핵심이다.

One of the tasks of the post- graduate clinical teacher is to minimise this risk while maximising the educational opportunity. Knowing when to take over and when to let go are key skills here.

교육/수련/진료 수행

Delivering education, training and service

교수들도 일상적인 업무가 있다. 

postgraduate medical faculty have a day job.

피훈련자들도 근무외시간의 일이 있고, 동시에 교육과정과 평가 요건을 충족시키기 위한 진료를 수행해야 한다.

Trainees too have to man out-of-hours rotas and deliver a service at the same time as satisfying the curriculum and assessment requirements

PGME에서의 교수개발의 과제

CHALLENGES FOR FACULTY DEVELOPMENT IN POSTGRADUATE MEDICAL EDUCATION

영국에서 교수개발은 patchy하고 교육병원을 중심으로 집중되어 있으며, PGME 훈련기관에 지원되는 재정은 sporadic하다. Trainer training의 가장 큰 장애요인은 재정 부족과 직무계획에 공식적으로 기술된 시간의 부족으로 알려져 있다.

In the UK, faculty development is patchy, concentrated around teaching hospitals and sporadically funded through postgradu- ate training institutions (deaneries). The main barriers to training the trainers are cited as funding constraints and the lack of time formally recognised in job plans.

이것은 영국만의 문제는 아닌 것으로 보인다. 미국에서도 교수개발의 local delivery에는 문제가 많다.

And this is not just a UK problem. Evidence suggests that local delivery of faculty development in the USA is also problematic.23

적어도 영국에서는, 병원 바깥에서의 그림이 더 장미빛이다. 일부 경우에서 GP는 trainer를 교육할 경우 합당한 인정을 받는데, 세션당 혹은 주당 훈련에 대해서 보상을 받는다.

Outside hospital, in the UK at least, the picture is more rosy. For some time, general practice has given due recognition to its trainers, who receive a one session/week training payment, as well as 100%reimbursement of the trainee’s salary.

어디로 가야할 것인가?

WHERE NEXT WITH FACULTY DEVELOPMENT?

PGME에서 퀄리티에 대한 논의가 등장하고 있으며, clinical teacher에 대한 요건은 높아지고 있다. PMETB는 generic quality domain에 대한 요건expectations을 발간했으며, Gold Guide to Specialty Training도 training requirement를 내놓았다.

A quality agenda for postgraduate medical education is emerging, with heightened requirements for clinical teachers already in view. PMETB has published its expectations of training in a set of generic quality domains38 and the Gold Guide to Specialty Training39 has laid out the training requirements for clinical and educational supervisors.

이러한 발전은 consultant에만 국한되지 않으며, trainee도 ‘‘teacher training’’ 이 인턴, 레지던트 수련과정에 포함되어 이 요건을 만족시키기 위해서는 training course를 밟고자 할 것이다.

This development will not be confined to consultants, and trainees will want to undertake training courses before qualifying as requirements for ‘‘teacher training’’ feature in both Foundation and specialty training curricula.

핵심이슈는 funding과 교육의 의의를 중시하는 직무계획일 것이다.

The key issues will be to engage the service in the business of education, which will be largely dependent on how the funding of training posts is orchestrated in the future, and to negotiate meaningful job plans that value education as a core, rather than as a peripheral activity.

6. Kaufman D, Mann K. Teaching and learning in medical education: how theory can inform practice. In: Understanding medical education. Edinburgh: Association for the Study of Medical Education, 2007.

38. Postgraduate Medical Education and Training Board. Generic standards for training. 2006. http://www.pmetb.org.uk/fileadmin/user/Policy/Policy_Statements/ Generic_standards_for_training_April_06.pdf (Accessed 4 February 2008).

39. Department of Health. A guide to postgraduate medical education in the UK (The Gold Guide). MMC: Department of Health, 2007.

 

 

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Postgrad Med J. 2008 Jul;84(993):339-43. doi: 10.1136/pgmj.2008.068288.

See one, do one, then what? Faculty development in postgraduate medical education.

Swanwick T1.

Author information

• 1London Deanery, Stewart House, 32 Russell Square, London WC1B5DN, UK. tswanwick@londondeanery.ac.uk

Abstract

Interest in the development of medical educators working in the postgraduate sector is running high. Driven by three interlinked trends--the professionalization of medical education, increasing accountability, and the pursuit of educational excellence--there is a growing need for high quality and sustained faculty development programmes across the network of education providers. Postgraduate medical education has a number of unique features that set it apart from undergraduate medicine, to which faculty development programmes need to cater. The key issue for the future will be how to engage the service in the business of education. Widespread cultural change is required and this will require effective and sympathetic leadership from postgraduate training institutions, hospitals and health authorities.

PMID:

 

18716011

 

[PubMed - indexed for MEDLINE]