과거를 되돌아보고 미래로: 새로운 세대의 의학교육자에게 보내는 메시지(Med Educ, 2011)

과거를 되돌아보고 미래로: 새로운 세대의 의학교육자에게 보내는 메시지(Med Educ, 2011)

Looking back to the future: a message for a new generation of medical educators

Ronald M Harden

INTRODUCTION

내 삶을 세 가지 시기로 나눠서 볼 것이다.

I will look at my journey in three phases.

• The first 12 years, from 1960 to 1972, I spent in Glasgow, where I developed an interest in medical education that evolved alongside my training as an endocrinologist and my work in research in iodine metabolism and thyroid disease.

• The second phase represents the 30 years from 1972 to 2002, spent in Dundee, where, while continuing to practise as a clinician and a clinical teacher, my interest and commitment increasingly turned to medical educa- tion.

• The final phase of the journey covers the period from 2002 to the present, following my retirement from my post at the University of Dundee, when new opportunities arose.

This was a point made by Christopher Lawrence,2 medical historian to the Wellcome Museum, in a review of the book Retro- spectroscope: Insights into Medical Discovery by Julius H Comroe. Lawrence wrote: ‘His retrospectroscope (a barbarous neologism history) is not the finely honed tool he thinks, but a blunt instrument for bludgeoning the doubtful.’2

제1기: 글래스고에서 의학교육에 대한 관심을 품다

PHASE 1: 1960–1972. DEVELOPING AN INTEREST IN MEDICAL EDUCATION IN GLASGOW

제2기: 던디에서 의학교육을 전공으로 삼다

PHASE 2: 1972–2002. MEDICAL EDUCATION AS A SPECIALTY IN DUNDEE

효과적 학습을 위한 CRISIS 준거(Convenience, Relevance, Individualisation, Self-assessment, Independent learning, Systematic approach) 는 CME분야의 대규모 연구의 결과로부터 유도되었다. 비록 CME영역에서는 편의성, 관련성, 개별성, 자기평가, 관심과 동기, 시스템적 접근(convenience, relevance, individualisation, self-assessment, interest and motiva- tion and a systematic approach)이 확립되어 있었지만, 이러한 아이디어가 학부교육에도 동등하게 적용가능하다.

The CRISIS (Convenience, Relevance, Individualisation, Self-assessment, Independent learning, Systematic approach) criteria for effective learning were derived fromthe findings of large-scale implementation stud- ies inthe fieldof continuing medical education(CME) involving in excess of 50 000 general practitioners.20 Although the concepts of convenience, relevance, individualisation, self-assessment, interest and motiva- tion and a systematic approach were established in the context of CME, these ideas were found to be equally applicableinundergraduate education.

 

제3기: 지평을 넓히다.

PHASE 3: 2002 TO THE PRESENT. EXPANDING HORIZONS

 

교훈

LESSONS LEARNED

Ian Stronach는 "승리의 서사"라고 부르는 것에서 성공의 중요성을 지나치게 강조하고, 그럼으로써 불가능한 선례만을 남겨놓고 후계자들에게 잘못된 선로를 놓는 것을 지적했다. 찬양성 글은 교육학적으로 막다른 길이다.

Ian Stronach23 attacked what he called ‘victory narratives’ for their over- emphasis of the importance of success, their laying of false trails and for the impossible exemplars they leave to those who follow. Departure eulogies, he argued, offer a pedagogic dead end for those who remain. I hope this account is not read as such a narrative of victory and I would be dismayed if it was.

교훈1: 사람이 중요하다

Lesson 1: people are important

놀라운 결론은 아니지만 언급할 가치는 있다. 모든 사람이 당신이 하려는 것에 공감하지 않을 것이라는 사실을 받아들여야 한다. 

This is not a surprising conclusion, but it merits stating. Much of what I have been able to achieve I attribute to the many powerful role models and outstanding colleagues with whom I have had the good fortune to work. I wonder how many professors of medicine today are similar role models, emphas- ising clinical practice at its best, and how many of them are enthusiastic teachers familiar with the names of all their students and personally committed to going out of their way to support their junior staff. Continuous exposure to working with individuals who encourage curiosity, new ways of thinking and, collectively, the sharing of knowledge is of the greatest importance. One has to accept that not everyone will be sympathetic to what one is trying to do, as is highlighted in the following extract from a personal letter I received from a professor in Dundee following the curriculum revision: ‘One wonders whether this will be the fate of medical education. Certainly I believe that Dundee’s current strategy will lead to disaster.’

 

만약 당신이 아무도 화나게 하지 않는다면, 아마도 당신은 어떤 중요한 것도 하고 있지 않은 것일지도 모른다.  사람들, 그리고 그들이 무슨 생각을 하는지가 중요하다.

If you upset nobody, however, perhaps you’re not doing anything of significance. People, and what they think, are important.

교훈2: 의학교육의 혁신은 복잡하다.

Lesson 2: innovation in medical education is complex

좋은 학문-중심 교육과정이 제대로 통합되지 못한 교육과정보다  나으며, 잘 통합된 교육과정은 poor 한 학문-중심 교육과정보다 낫다.

At a conference organised by the Graves Audio- visual Library (an initiative well ahead of its time), I listened to the presentations of two papers onwhat, at the time, was a topical subject. The results, how- ever, simply reflected the expertise of the producer rather than the choice of media. More important than the educational or assessment technique adopted is the expertise with which it is employed. A good discipline-based curriculum is better than a poor integrated one, and a good integrated curriculum is better than a poor discipline-based one.

교훈3: 넛지가 중요하다.

Lesson 3: nudges are important

넛지란 특정 행동을 강요하기보다는 장려하는 방식의 정책 개입을 말한다. 비근한 예로 남자 소변기에 파리를 그려놓은 것과 같은 것이다. 의학교육은 본질적으로 과학적 토대를 둔 social discipline이라는 점을 잊어서는 안된다.

Nudges are defined as policy interventions that encourage rather than mandate certain types of behaviour. The authors cite, as a classic example, the painting of a fly on urinals at Amsterdam airport.24 The use of the pilot OSCE in Dundee to gain its acceptance for use as a formal part of the Dundee final examination is another example of a nudge. Medical education is essentially a social discipline with scientific underpinnings and we should not forget this. Nudges can be important.

교훈4: 학생도 중요한 플레이어이다.

Lesson 4: students are important players

 

교육과정에 대한 학생의 잠대력을 과소평가해서는 안된다. 이들은 중요한 이해관계자이며 교육과정을 계획하는데 중요한 기여를 할 수 있고, 변화의 동력이 될 수 있다.

It is important not to underestimate students’ poten- tial input to the curriculum. They are important stakeholders; they can make important contributions to curriculum planning and they can be drivers for change.

학생-중심 학습, 독립적 학습에 대해서 논할 때, self-directed learning보다는 directed self-learning을 목적으로 삼는 것이 중요하다. Jon Dron은 교사의 중요한 과제 중 하나는 학생의 발달 단계에 맞춰 학생에게 스스로의 학습에 대해 얼마나 많은 통제권을 부여할 것인가를 결정하는 일이라고 하였다.

When thinking about student-centred and indepen- dent learning, it is important to have as the aim directed self-learning rather than self-directed learning. In his book Control and Constraint in E-Learning, Jon Dron25 made the important point that one of the main challenges for the teacher is to decide at the different stages in students’ development how much control students should be given over their own learning.

학생에 대해 논할 때, 오늘날의 학생은 과거의 학생과 매우 다르다는 것을 인식해야 한다. 우리가 digital immigrants라면 지금의 학생은 digital native이다. 또 다른 점은 학생은 균일한 집단이 아니며 각자가 다른 니즈를 가지고 있다는 점이다. 미래의 핵심 트렌드는 개별 학생의 니즈에 맞는 adaptive learning을 개발하는 것이 될 것이다. 학교의 수월성의 척도 중 하나는 극단에 있는 학생을 어떻게 다루느냐가 될 것이며, 여기에는 고성취 학생과 struggler를 모두 포함한다.

When thinking of students, we need to recognise that students today are very different from the students with whom we studied medicine. We may be ‘digital immigrants’, but contemporary students, as described by Prensky,26 are ‘digital natives’. Another point worth remembering is that students are not homogeneous, They each have different needs. A key trend in the future will be the development of more adaptive learning that is customised to meet the needs of individual students. One measure of excellence of a school should reflect how well it deals with the extremes among its students, including both the high achievers and those who are struggling or in difficulty.

교훈5: 현실적인 해결책을 제공하라.

Lesson 5: offer practical solutions to problems

의과대학의 학장, 교사, 행정가들은 현실적 문제에 대한 답을 원한다.

The dean, teachers and administrators in the medical school expect answers to practical problems.

교훈6: 자기가 하고 있는 것 바깥에서 배울 점이 늘 있다.

Lesson 6: there is always something to learn outside one’s practice

교육자로서 우리는 같은 분야의 저널을 읽고, 학회에 참석하고, 사람들을 만난다. 미국의 교육학자 Royal van Horn은 일 년에 한 번은 관심 분야 외의 교육 컨퍼런스에 참여할 것을 권했다.

As educators, we have a tendency to read journals, attend conferences and communicate with people working in our own area. Royal van Horn, an eminent American educationalist, argued that, once per year, teachers should attend an education conference out- side their own immediate area of interest. I have tried to do just that.

만약 우리가 의학교육에서 진정한 진보를 이루고 새로운 패러다임을 개발하기 위해서는 내용전문가, 교육과정 개발자, 교육학자, 교육공학자, 교육설계가, 심리학자 등의 더 많은 협력이 필요하다. '메디치 이펙트'에서 강조한 것처럼 여러 학문의 교차점에서 진보가 이뤄질 것이다.

I argued that if we are to make real progress in medical education and develop new paradigms, we need to ensure greater collaboration between content experts, curriculum planners, educationists, learning technol- ogists, instructional designers and psychologists. As Frans Johansson27 highlighted in his book The Medici Effect, it is at the intersections between different disciplines that progress will be made.

 

교훈7: 출판하라.

Lesson 7: publish

내가 다시 산다 해도 내가 한 일을 기록하고 출판하는데 더 큰 우선순위를 둘 것이다. 오늘날에는 더욱 중ㅇ해졌다.

Although I have published well in excess of 400 papers in-peer reviewed journals, if I had to live my life again I would place greater priority on documenting what I did and publishing it. Publishing is even more important today, when professionalismand scholarship in medical education are crucial. As editor of Medical Teacher, however, I see how badly many authors approach the publishing challenge.

교훈8: 역사에서 배우라

Lesson 8: learn from history

Paul Saffo는 '우리의 역사적 거울을 미래를 예측하는 강력한 도구로 사용할 것이며, 과거 사건의 결texture이 현재의 지표가, 그리고 미래의 궤적의 신뢰성 있는 지도가 될 것이다. 다만, 충분이 과거를 돌아봤을 때 말이다'라고 했다.

Paul Saffo, writing in the Harvard Business Review, suggested that, when making a decision, we should look back twice as far as we look forward.28 He argued: ‘…used properly, our historical review mirror is an extraordinary powerful forecasting tool and the texture of past events can be used to connect the dots of present indicators and thus reliably map the future’s trajectory – providing one looks back far enough.’28

교훈9: 독립적인 펀딩을 확보하라

Lesson 9: obtain independent funding

Convincing commercial organisations, professional bodies, philanthropists, patient organisations and governmental funding agencies that they should fund research and development work in medical education was and remains challenging. Arguing the case for funding to the respective body was itself a challenge, but proved to be a useful exercise as it helped to ensure clarity of thinking. It should be recognised, however, that, at a time of financial constraint, the funding of work in medical education is not easy.

교훈10: 즐겨라!

Lesson 10: have fun!

결론

CONCLUSIONS

비록 나에게 훌륭한 동료들이 있지만, 의학교육 혁신에 대한 나의 접근이 언제나 인정받았던 것은 아니며, 모든 사람이 편안해하는 것도 아니라는 사실을 받아들여야 했다. 내 철학은 Ian Stronach의 스펙트럼과 정반대에 있었던 듯 하다. 그는 "이끌지 않음으로써 이끌고, 통제하기보다는 동기를 부여하고, 주도권을 쥐기보다는 주도권을 만들어내고, 공간을 채우기보다는 공간을 만들고, 지시하기보다는 멘토링을 하고, 협력적이고 상대적으로 민주적인 기풍을 만든다'고 했다. 나는 사실 동제하려는 성향이 강하고 진행과정을 막는 사람에 대해서는 참아내지 않았다. 그러나 나를 이끌어준 것은 의학교육의 역할을 통해서 세계world를 도우려는 것이었다. 만약 내가 epitaph를 고른다면, 다음이 딱 적당할 것 같다.

Although I have had many wonderful colleagues, my hands-on approach to innovation in medical education has not always been appreciated and I have had to accept that not everyone is comfortable with it. I suppose that my own philosophy could be defined as located at the opposite end of the spectrum to that of Ian Stronach, who describes his view as one of ‘leading by not-leading, motivating rather than controlling, making rather than taking initiatives, creating spaces rather than filling them, mentoring rather than directing and developing a collaborative and relatively democratic ethos’.23 I have to confess to a more controlling tendency and an impatience with anyone who seems to obstruct progress. What has driven me, however, is more a desire to help to shape the world in so far as this is possible through a role in medical education, rather than to document what has been done in the field. If I had to choose an epitaph, I could think of nothing better than the following West Point Military Academy cadet maxim:

안전보다는 위험을 감수하라. 현명함보다 케어care에 신경쓰라. 현실적인 것을 넘어서 꿈을 꾸라. 가능한 것 이상을 상상하라

‘Risk more than others think is safe. Care more than others think is wise. Dream more than others think is practical. Expect more than others think is possible.’

Appendix S1 Looking Back to the Future: A message for a new generation of medial educators.

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Med Educ. 2011 Aug;45(8):777-84. doi: 10.1111/j.1365-2923.2011.03934.x.

Looking back to the future: a message for a new generation of medical educators.

Harden RM1.

Author information

• 1Association for Medical Education in Europe (AMEE), 484 Perth Road, Dundee, UK. r.m.harden@dundee.ac.uk

Abstract

OBJECTIVE:

Many changes in medical education have occurred during the author's 50-year career in the field. The aim of this paper is to describe 10 lessons worth recording for others engaged in the training of health care professionals.

THREE CAREER PHASES:

The first phase in the author's career occurred during 1960-1972 in Glasgow, where an interest in medical education developed alongside an engagement in clinical medicine and research into iodine metabolism. The second phase took place during 1972-2002 in Dundee, where, after working for a period as a clinician, the author made a full-time commitment to medical education. The third phase, from 2002 to the present, has provided the opportunity to explore new horizons in medical education.

CONCLUSIONS:

The following lessons have been learned. (i) People are important as role models and collaborators. (ii) Innovation in medicaleducation is a complex process and research findings can easily be misinterpreted. (iii) Nudges, interventions that encourage rather than mandate change, are valuable. (iv) Students are important players in planning, delivering and evaluating a curriculum. Each student has different needs and aspirations. They are the 'digital natives'. (v) Offer stakeholders practical solutions to problems that can be implemented. (vi) There is always something to learn outside one's own practice. Go to a conference or read a journal in a related field. (vii) Time spent recording one's work and publishing reports based on it is rewarding. (viii) Learn from history. We don't need to keep reinventing the wheel. (ix) Obtain independent funding. (x) Finally, and most importantly, have fun. Working in medical education can be exciting, fulfilling and hugely enjoyable.

© Blackwell Publishing Ltd 2011.

PMID:

 

21752074

 

[PubMed - indexed for MEDLINE]