자기주도학습: 왜 여전히 교수들은 잘못하고 있는가? (IJSDL, 2013)

SELF-DIRECTED LEARNING: WHY DO MOST INSTRUCTORS STILL DO IT WRONG?

Roger Hiemstra

Instructional/Facilitator Roles 

교수의 역할은 다음과 같다.

Instructional/Facilitator roles that work for me in promoting corresponding personal responsibility among adult learners are listed below.

1. 내용 전문가/제공자

1. Content resource

서적 자료나 인터넷, 발표자료, 면대면, 온라인 토론 등등을 통해서 전문성과 지식을 공유한다.

Sharing expertise and knowledge with learners through written material, web pages, presentations, face to face or online discussions, and one-on- one advising, conversations, counseling, and coaching (Posner, 2009). 

2. 자원 배분자

2. Resource locator

다양학 학습자원을 배분하고 공유하여 학습경험 중 드러난 학습요구를 충족시킬 수 있게 한다. 서적 자료, 인터넷 자료, 다양한 사람을 만날 수 있도록 촉진하는 것(기관 방문), 작은 인턴십, 주제별 전문가와의 대화 등이 될 수 있다.

Locating and sharing various learning resources to meet needs identified and emerging during learning experiences. These can include written materials, Internet resources, and facilitating for learners various people-oriented experiences such as agency audits or visits, mini-internships, and talking with topic specialists. 

3. 관심 유발자

3. Interest stimulator

면대면 혹은 온라인, 다양한 학습자원, 학습 경험을 조직화하고 활용하여 학습자의 관심을 유발할 수 있도록 설계한다. 게임 기계, 소그룹 토론, 온라인 비동시 포럼, 면대면 혹은 온라인 게스트 발표, 유머러스한 PPT발표 등도 포함된다.

Arranging for and employing, face-to-face or online, various resources and learning experiences designed to maintain learner interest such as gaming devices, small group discussions, online asynchronous forums, face-to- face or online guest presentations, and even humorous PPT presentations.

4. 긍정적 태도 유발자

4. Positive attitude generator

학생들의 자신감을 높이고 건설적 피드백과 개인적인 격려, 긍정적 강화, 폭넓은 비평을 통해서 스스로 학습 결정을 내릴 수 있도록 한다.

Helping students gain increasing confidence in making personal learning decisions via constructive feedback, personal encouragement, positive reinforcement, and extensive critique of written material. 

5. 창의성과 비판적 사고 유발자

5. Creativity and critical thinking stimulator

토론, 스터디그룹, 일기, 독서그룹, 롤플레이, 그림을 이용한 일기, 관련된 사람의 전기 작성 등을 활용하여 학습자의 창의성과 비판적 사고 기술을 자극한다. 웹페이지나 블로그를 만들게 하는 방법도 있다.

Stimulating a learner's creative and critical thinking skills through discussions (face-to-face or online), study groups, journal writing (Hiemstra, 2001), interactive reading logs, role playing, creating a written or pictorial autobiography (Hiemstra, 2011b), writing a biography of a relevant individual, or various ways of stimulating real-life experiences. Additional means include helping learners develop web pages or blogs as an electronic technique for sharing what they have developed. 

6. 평가 촉진자

6. Evaluation stimulator

학습자의 진전을 평가하고 자신들이 스스로 자기평가를 하게끔 한다. 학습계약은 학습자들이 교수자, 동료, 기타 다른 사람들을 자기자신의 학습노력을 평가하는데 활용할 것인지를 생각하게끔 도와준다.

Evaluating learner progress and stimulating self- evaluation by learners. The learning contract provides opportunities for learners to think about how they can use an instructor, colleagues, and others to enhance personal evaluation of their learning efforts.

My Colleagues Voice Their Opinions

• Encouraging Students to Take Individual Initiative

• Using Learning Contracts

• Why Do Teacher-Directed Approaches Still Dominate?

• Why Do Most Still Do It Wrong?

왜 여전히 잘못하고 있는가에 대한 나의 생각

Why I Believe Most Still Do It Wrong

우선, 나는 교수철학에 대해서 개인적인 진술서를 가지고 있는 것이 매우 중요하다고 생각한다. 왜냐면 그러한 철학이 가르치는 방향을 정하기 때문이다. 우리가 말하고 믿는 것과 우리가 다른 사람과의 관계에서 실제로 행하는 것 사이의 비일관성을 바라보기 시작한다면 변화의 기전이 될 수도 있다.

To begin with, I have long contended that it is very important to develop a personal statement of instructional philosophy because such a philosophy drives the way we teach. A statement of philosophy also can be a mechanism for changing the way we teach if we begin to see inconsistencies between what we say we believe and what we actually do in our interactions with others, especially students (Hiemstra, 1988b).

이러한 점에 더하여 나는 많은 교수들이 전통적인 교수자 중심적 접근법을 따르는 것은 그들의 행동주의적 관점, 특히 그들이 배운 선생님으로부터 형성된, 그리고 그들이 학생이었을 때 경험으로부터 형성된 그러한 관점을 학습자를 대하는 가장 좋은 수단으로 여기기 때문이다. 일부 교사들은 진심으로 학생들에게 그들이 알아야 할 지식을 말해주는 것이 자신의 역할이라고 믿는다. 그러나 나는 이렇게 행동주의에 의존하는 것은 의도치 않게 많은 학습자의 성장과 발달을 저해할 수 있다고 생각한다.

Related to the above point, I believe that many teachers employ traditional teacher-directed approaches because their views of behaviorism, often modeled after former teachers and their own experiences as learners, are seen as the best means for working with learners. Granted some teachers truly believe that their role is to “tell” students the knowledge they need to know. However, my beliefs based on nearly forty years of SDL scholarship suggest that reliance on behaviorism may unintentionally inhibit the growth and development of many learners by creating dependency (Hiemstra & Brockett, 1994).

나는 종종, 어떤 선생님들은 얼마나 그 학생들로부터 받은 코멘트를 심각하게 여기는지 궁금하다. 일부 고등교육기관은 매 코스가 끝난 다음 그 과정에 대한 평가를 요구한다. 이러한 자료를 사용하는 것은 교수방법적 접근에 큰 차이를 가져온다.

I often wonder, too, how seriously some teachers take the evaluative comments coming from their learners. Admittedly, some higher education institutions mandate evaluation procedures after each course is completed. However, utilizing such information to make significant changes in instructional approaches takes a real effort.

마지막으로, 지난 수십년간 교수법 향상에 대해서 기관 차원의 후원은 축소되어왔다. Schylinski가 말한 바와 같이, 대부분의 대학 교수들이 스스로 알아서 하게끔 방치되는 현실과 대부분이 그들이 경험한대로 하는 현실에 우려를 표한다.

Finally, I have observed during my several decades of teaching that there has been a diminution of institutionally sponsored or promoted opportunities for instructional improvement. As supported by Schylinski (2012) in her research, I fear that today a majority of college professors are often left to their own devices and must rely mainly on modeling their instruction on what they experienced in classrooms themselves as students.

어떻게 SDL의 잠재력을 더 널리 전파할 수 있을까?

How Do We Better Disseminate the Potential of SDL?

• The development of several Web site(s) devoted to promoting the use of SDL and ? II with such items as supportive essays from several faculty, testimonials from students, examples of such approaches or techniques as learning contracts, and models of instructional materials that can be utilized. Following are three such

• Web site examples: 

(a) http://www.sdlglobal.com/; 

(b) http://selfdirected learning .com/; and 

(c) http://www-distance.syr.edu/distancenew.html.

• The development and publishing of various video clips through such sources as ? YouTube, Meta Cafe, and Google Video that describe SDL, how it can be used, and successes that are possible. Following are three YouTube examples: 

o http://www.youtube.com/watch?v=kqZR6ZJsKJA 

o http://www.youtube.com/watch?v=AexdB8aBi8I 

o http://www.youtube.com/watch?v=fkEydFhZj9Y.

Schylinski 가 면담한 한 사람은 이렇게 말했다.

One of the people interviewed by Schylinski (2012) in her research, a professor of religious studies, revealed how he is working to incorporate SDL approaches in his teaching: 

“I take adult learning theory seriously. You must treat students as adults, with respect, as having capacity to learn for themselves, and taking responsibility to learn. The fundamental reality is I will have them for a short time. If I don’t enable or encourage their fundamental ability to learn on their own, what have I done? My hope is when they leave, they will be lifelong learners” (pp. 56-57).

Gross and Salko 의 말이 잘 표현해준다.

Gross and Salko (2013) perhaps say it best: 

“How will we learn most and best in the 21st century? We believe it will be through self-directed learning (SDL).”

SELF-DIRECTED LEARNING: WHY DO MOST INSTRUCTORS STILL DO IT WRONG?

Roger Hiemstra

In a recent article in this journal I described how most instructors of adults use a teacher-directed approach in spite of the SDL scholarship and lost learner potential. In this article I describe why this apparent disconnect takes place. In addition, twelve teaching colleagues provide their ideas relative to why many teachers fail to utilize SDL approaches. They also describe their own experiences in helping learners take increasing responsibility for their own learning. I add my own ideas on why many instructors still do it wrong and end by suggesting various ways to better advocate for SDL processes, techniques, and instructional approaches in classrooms.

성찰의 수준: 현미경, 혹은 쌍안경(IJSDL, 2013)

LEVELS OF REFLECTION: THE MIRROR, THE MICROSCOPE, AND THE BINOCULARS

Tanya McCarthy

거울

The Mirror

Guided questions asked in the report to trigger a more reflective response were:

• What are my strengths and weaknesses?

• What surprised me about myself?

현미경

The Microscope

Guided questions asked in the report to trigger a more reflective response were:

• What did I do well?

• What do I need to improve?

• How have I improved from point A to point B?

쌍안경

The Binoculars

Guided questions asked in the report to trigger a more reflective response were:

• What are my goals for my future?

• What skills will help me in my university career and beyond?

Levels of Reflection in Self-Directed Learning

O’Malley and Chamot은 "메타인지적 접근을 하지 않는 학생은 방향을 잃은 것과 마찬가지이며, 자신의 진전과 성취, 미래에 나아갈 방향을 되짚어 볼 능력이 없는 것과 같다"라고 했다. Burnard와 Chapman에 따르면 자기성찰적 질문에는 주로 두 수준이 있다. 심층적 유의미한 질문과 피상적 문제해결이다. 학생들의 최종 보고서를 분석한 결과  자기주도학습에 대해서 깊은 수준의 성숙이 있었던 것이 확인되었다. 다양한 구조화된, 혹은 비구조화된 성찰 모델을 활용하여 학생들은 단순히 일어난 일을 기술하는 것이 아니라 적절하고 관련된 목표를 세우고, 활동 계획을 수립하고, 변화를 관찰하고, 변화를 모니터링하고, 일어난 사건을 해석하고, 다음에 무엇을 해야할지 이론을 세우고, 스스로의 발전을 평가하였다.

O’Malley and Chamot (1990) state, “students without metacognitive approaches are essentially learners without direction and ability to review their progress, accomplishments and future learning directions” (p. 99). According to Burnard and Chapman (1988), there are two main levels of reflective enquiry: deep and potentially meaningful inquiry and superficial problem solving. Analysis of students’ final reports showed a deeper level of maturity in students related to the progress made in their selfdirected learning. Incorporating various structured and unstructured modes of reflection in the course (as shown previously in Figure 1), encouraged students to go beyond a mere description of events (which was prevalent in the pilot course) to setting appropriate and relevant goals, planning an action, observing changes, monitoring progress, interpreting events, theorizing about what to do next, and evaluating their own progress (see Figure 5).

여러 연구문헌에서 정의한 '성찰'

Boud, Keogh and Walker (1985)

Reflection is an important human activity in which people recapture their experience, think about it, mull it over and evaluate it. It is this working with experience that is important in learning (p. 19).

…Those intellectual and affective activities in which individuals engage to explore their experiences in order to lead to new understandings and appreciations (p. 19)

Dewey (1933) 

Active, persistent, and careful consideration of any belief or supposed form of knowledge in the light of the grounds that support it and the further conclusion to which it tends, constitutes reflective thought (p. 9).

Schön (1983) 

The practitioner allows himself to experience surprise, puzzlement, or confusion in a situation which he finds uncertain or unique. He reflects on the phenomenon before him, and on the prior understandings which have been implicit in his behaviour. He carries out an experiment which serves to generate both a new understanding of the phenomenon and a change in the situation (p. 68).

Smith (2001)

The act of reflecting-on-action enables us to spend time exploring why we acted as we did, what was happening in a group and so on. In so doing we develop sets of questions and ideas about our activities and practice

Schunk and Zimmerman (1998)

Self-regulation theorists view learning as an open-ended process that requires cyclical activity on the part of the learner that occurs in three major phases: forethought, performance or volitional control, and self-reflection…self-reflection, involves processes that occur after learning efforts and influence a learner’s reactions to that experience (p. 2).

Jarvis (1987) 

Reflection is an essential phase in the learning process whereby people explore their experiences in a conscious manner in order to lead to a new understanding and, perhaps, a new behavior (p.168).

King (2002) 

Critical reflection is taken to mean a deliberate process when the candidate takes time, within the course of their work, to focus on their performance and think carefully about the thinking that led to particular actions, what happened and what they are learning from the experience, in order to inform what they might do in the future (p. 2).

York-Barr, Sommers, Ghore and Montie (2001)

It is a complex process that requires high levels of conscious thought as well as a commitment to making changes based on new understanding of how to practice (p.4).

Reflective practice is “a deliberate pause to assume an open perspective, to allow for higher level thinking processes. Practitioners use these processes for examining beliefs, goals, and practices, to gain new or deeper understandings that lead to actions that improve learning for students” (p.6).

Hatton &Smith (1995)

Deliberate thinking about action with a view to its improvement (p. 52).

LEVELS OF REFLECTION: THE MIRROR, THE MICROSCOPE, AND THE BINOCULARS

Tanya McCarthy

Abstract

This paper analyzes the written reflections of 18 freshman students in a self-directed learning course. In the pilot course, it was found that the depth of students’ reflections was limited to mainly short answers or surface reflections. Students reported that they found it difficult to understand the concept of reflecting on learning. A new course that placed more emphasis on various levels of reflection was designed with the specific aim of helping students to reflect more deeply on their learning so that they could be more aware of why they were doing what they were doing and see their accomplishments. The course culminated in a final 500-word report in which the students were asked to reflect on what they learned about themselves (the mirror), strengths and weaknesses they identified in their learning (the microscope) and how this connected to their life outside the classroom and into the future (the binoculars).

성인학습자로 가는 길: 의존적 학습자에서 자기주도적 학습자로 (J Am Coll Cardiol, 2014)

The Journey to Becoming an Adult Learner: From Dependent to Self Directed Learning

Joshua A. Daily, MD; Benjamin J. Landis, MD

당신이 의과대학에서 배운 것중에 절반은 졸업 후 5년 이내에 사라지거나 틀렸음이 증명될 것이다. 문제는, 거기에 해당할 것들이 무엇인지 알려줄 수 있는 사람이 아무도 없다는 것이다. 따라서 가장 먼저 배워야 할 것은 스스로 학습하는 방법이다.

“Half of what you’ll learn in medical school will be shown to be either wrong or out of date within 5 years of graduation; the trouble is that nobody can tell you which half, so the important thing to learn is how to learn onyour own.”—David L. Sackett, OC, MD (1) 

성인학습을 설명하는 다양한 모델이 있지만, 가장 잘 알려진 노력은 Malcolm Knowles가 설명한 Andragogy이다. 다음의 여섯 가지 가설에 기반한다.

Although many models exist to explain adult learning, the best known of these efforts is andragogy (meaning “theart and science of helping adults learn”), which was described by Malcolm Knowles and is based upon the 6 following assumptions (2,3): 

1. 사람이 성장할수록 그의 자기개념은 의존적인 인성에서 자기주도적 인간으로 나아간다.

1. As a person matures, his or her “self-­concept” moves from that of a dependent personality toward one of a self­directing human being. 

2. 성인은 경험을 축적해나가며 이것은 학습의 원천이 된다.

2. An adult accumulates a growing reservoir of experience, which is a rich resource for learning.

3. 한 성인의 학습에 대한 준비도는 그의 사회적 역할상의 발달과업과 관련되어 있다.

3. The readiness of an adult to learn is closely related to the developmental tasks of his or her social role.

4. 사람들이 성장하면서 시간에 대한 관점이 바뀌는데, 처음에는 지식을 미래에 적용하는 것에서 즉각적인 적용으로 바뀐다.

4. There is a change in time perspective as people mature, from future application of knowledge to immediacy of application. 

5. 가장 강력한 동기는 외적 동기보다는 내적 동기이다.

5. The most potent motivations are internal rather than external.

6. 성인은 왜 무엇을 배워야 하는가를 알아야 한다.

6. Adults need to know why they need to learn something.

소수의 성인만이 이 원칙을 온전히 습득하고 있으며, 따라서 이 원칙들은 성인학습이 어떠해야 하는가에 대한 지시문으로 보는 것이 낫다. Knowles는 이 프레임워크에서 필수적인 요소는 SDL이라 하였다.

Few adult learners fully embody each of these principles, and thus, the principles may be best considered as prescriptive statements for what adult learning should look like. Knowles recognized that within this framework,the essential factor is self­directed learning, 

불행하게도, 전통적인 의학 교육과정은 SDL을 촉진하기에 부적절하며, 이 과정은 의사들이 스스로 해야 하는 과제로 남는다. 이러한 gap에도 불구하고 우리는 가장 강력한 가능한 근거를 우리의 경험과 주위의 조언에 더해서 다음의 권고를 한다. 

Unfortunately, the traditional medical school curriculum often inadequately promotes self­directed learning, so physicians are often left to make this transition independently (4,5). Despite this gap in early medical curricula, we have aimed to synthesize the strongest evidence available with referenceto our own experiences and advice of colleagues and mentors to encourage the following recommendations for fellows­in­training and early career cardiologists on becoming self­directed life­long learners. The specific Knowles’ assumptions from which each recommendation was developed are provided in italics. 

1. 학습의 주도권과 책임을 가지라

1. Take initiative and responsibility for your learning. 

당신이 해야 할 교육이란 스스로의 전문성에 대한 교육이다. 주입식의 CME 프로그램은 의사의 행동에 영향을 거의 미치지 않음을 상기하라. 대신 스스로의 독특한 교육요구를 인식하고 그것에 대한 책임을 지라

Recognize that as an independent clinician your education is your own professional responsibility. You control what, when, and how you learn. It would be amistake to assume that fellowship completion and board certification is tantamount to completion of your education. Be aware that didactic continuing medical education programs can have limited impact on physician behavior (6). Rather, recognize your particular educational needs and take responsibility for themby developing regular habits that promote learning. Knowles’ assumptions 1, 3, and 5(2,3). 

2. 겸손한 태도를 가지라

2. Develop an attitude of humility. 

불확실성을 인정하고 스스로 답을 모른다는 사실을 인정하라. 과도한 자신감은 피드백을 얻고 평생학습을 하는데 장애가 될 뿐이다.

Acknowledge uncertainty and admit when you do not know the answer.Recognize that overconfidence is an impediment to the pursuit of feedback and life­long learning (7). Knowles’ assumptions 1 and 5(2,3). 

3. 질문을 하고 답을 찾아라

3. Ask questions and seek answers. 

탐구하는 자세를 가지고 의학과 과학에 대한 관심을 지속적으로 유지하라. 시간을 가지고 연구하여 질문에 대한 답을 찾으라. 질문에 대한 답을 찾기 위해서 효과적으로 문헌을 검색하는 방법을 익히라. 그리고 비판적으로 평가하고 관련 자료를 선택하고, 마지막으로 환자와 informed care decision을 내리라.

Sustain the inquisitive nature that compelled your interest in medicine and science and take the time to research answers to your questions. Learn to first efficiently perform a literature search to answer a focused question, then to critically appraise and select relevant resources, and finally, to make informed care decisions for the patient at hand and future encounters. Knowles’ assumptions1 and 4(2,3). 

4. 최신의 지식을 유지할 수 있는 시스템을 갖추라

4. Develop a system for remaining up to date. 

일반적인 주제를 다루는 저널과 특수한 주제를 다루는 저널을 모두 읽으라. journal watch를 생성하여 새로운 문헌을 놓치지 말라. 적절한 라벨을 붙이고, 정기적으로 컨퍼런스에 참가하라.

Read both general and specialty journals regularly, create a journal watch for new papers in your field, utilize technology to store important literature with adequate labels for easy retrieval, and routinely attend conferences. Reject the tendency to settle into the role of a dependentor passive learner, such as relying on continuing medical education requirements to stay informed. Knowles’ assumptions 1, 3, and 4(2,3). 

5. 비판적으로 성찰하라

5. Critically reflect. 

스스로를 정직하게 평가하는 습관을 길러라. "어떻게 하면 더 잘할 수 있었을까?"라고 스스로 물어라. 일지를 기록하는 식으로 스스로의 발전을 기록하라. 당신의 동료와 환자는 중요한 학습의 원천이다. 피드백을 요청하라.

Develop the habit of honestly assessing yourself. After a challenging clinical encounter,ask yourself: “How could I have done better?” Consider developing the practice of reflection through journaling. Your peers and patients are important sources for learning, so request feedback from them and conscientiously reflect on their input. Knowles’ assumptions 1 and 2(2,3). 

6. 목표를 설정하라

6. Set goals. 

스스로의 교육적 요구에 맞춰서 명확하고 구체적이고 가능하고 의미있는 목표를 세우라. 그리고 달성가능한 꼐획을 세우라. 반복적으로 스스로의 진전 정도를 평가하고, 필요하다면 새로운 목표를 만들라. 1개나 2개의 구체적인 토픽에 초점을 두라.

Based upon your educational needs, develop clear, specific, feasible, and meaningful goals, and then formulate an achievable learning plan to accomplish these goals. In an iterative process, regularly reassess your progress and adjust and create new goals as necessary. Consider focusing on 1 or 2 specifictopics at a time until you have mastered the information to avoid becoming overwhelmed. Knowles’ assumptions 1 and 5(2,3). 

7. 동료로부터 배우라

7. Learn from your colleagues. 

딜레마에 빠졌을 때 동료의 의견을 구하라. 서로 다른 수련을 받는, 다른 배경에 있는 사람의 의견을 구하라. 만약 동료가 명확한 설명 없이 조언만 준다면 그 주제를 스스로 더 찾아서 연구해보라.

When confronted with clinical dilemmas, ask for the opinion of your colleagues. Specifically, seek out the opinions of those with different training and background. If your colleague provides a recommendation without a clear explanation, spend the time to research the topicyourself. Ask noncardiology consultants to provide the rationale for their recommendations and the alternatives that they considered. Knowles’ assumptions 1, 2, and 4(2,3). 

8, 창조하라

8. Create. 

강의를 하거나, 교육과정을 짜거나, 독립적이거나 협력적인 연구 프로젝트를 하거나, 논문을 쓰거나, 교과서 집필에 참여할 기회를 찾아라. Bloom의 Revised Taxonomy에 따르면 '창조'는 인간 사고에서 가장 높은 수준에 해당한다.

Seek out opportunities to give lectures, craft educational curriculum, engage in independent andcollaborative research projects, write journal papers, and contribute to textbooks. According to Bloom’s Revised Taxonomy (a framework developed by psychologist Benjamin Bloom for categorizing educational goals), creating is the highest level of complexity of human thought and usually results in mastery of a subject matter (8). Knowles’ assumptions 1 and 2(2,3). 

9. 타 분야 개발에 힘쓰라

9. Develop your mind. 

비의학적인 학습을 해나가라. 한 분야에 대한 학습은 다른 분야를 더 강하게 해준다. 또한 의사는 환자에 대해서 전인적인 관점을 가질 수 있어야 한다.

Incorporate nonmedical learning into your life. Learning in 1 area enhances and strengthens learning in other areas (9). Additionally, physicians become well­rounded and develop a moreholistic perspective of their patients. Personally, I like to listen to audio books during my morning and evening commutes to accomplish this goal. Knowles’ assumptions 1 and 8(2,3). 

10. 의미를 가지고 배우라

10. Learn with sense and meaning. 

뇌는 정보를 저장할 때 논리적이고 의미가 있을 때 더 효율적이다. 단순히 암기하지 말고 당신에게 의미가 있는 프레임워크에 맞추라. 이것이 추가적인 일이 될 수 있지만 궁극적으로 더 오래 기억하게 해줄 것이다. 추가적으로 언제나 환자를 돌보는 것과 스스로의 전문성 개발과 어떤 관련이 있는지 생각하라. 

Your brain is efficient and most likely to store information that is both logical and meaningful (9). Don’t just memorize, but rather fit new learning into a framework that makes sense to you. This takes extra work, but it will significantly improve retention. Additionally, always keep in mind the relevance to patient care and your own professional development. In which scenarios will you applythis knowledge or in which of your past encounters could this information have improved an outcome? If youcan answer these questions, you are more likely to remember the information. Knowles’ assumptions 1, 4, and 6(2,3). 

J Am Coll Cardiol. 2014 Nov 11;64(19):2066-8. doi: 10.1016/j.jacc.2014.09.023. Epub 2014 Nov 3.

The journey to becoming an adult learner: from dependent to self-directed learning.

SDL 측정도구와 관련된 조절효과(IJSDL, 2013)

THE MODERATING EFFECT OF THE SELF-DIRECTED LEARNING MEASUREMENT TOOL: A USER’S GUIDE

Stefanie L. Boyer, Diane R. Edmondson, and Andrew B. Artis

SDL이 학문과 실용 모두에서 성인학습의 성공을 촉진한다는 것은 잘 알려져 있다. 

It is widely accepted that self-directed learning (SDL) promotes adult learning success in both academia (Brockett & Hiemstra, 1991; Knowles, 1975; Long, 2001; Speck, 1996) and practice (Artis & Harris, 2007; American Society for Training & Development, 2009; Boyer & Lambert, 2008; Burns, 1995; Durr, Guglielmino, & Guglielmino, 1996). There are over 1,600 articles and 600 dissertations on the topic in academia alone (Edmondson, Boyer, & Artis, 2012).

이론적 배경

Theoretical Background

자기주도성은 타고나는 것일 수도 있다. 혹은 연습을 통해서 독립적으로 향상될 수도 있다. 그리고 교수자에 의해서 향상될 수도 있다. 사실 Transformation theory에 따르면, 사람이 배우거나 새로운 기술을 익히거나 새로운 지식을 습득할 때 세계관이 진화하기 때문에 사람은 바뀐다. 이러한 방식으로 자기주도성도 변할 수 있다.

Self-directedness can be innate, stemming from personal characteristics; it can be learned independently through practice; and its development can be facilitated by an instructor. In fact, transformation theory (Mezirow, 1985) suggests that when people learn, develop new skills, and acquire knowledge, they change because their basic assumptions about the world evolve; in this way, their level of self-directedness can change.

전 세계에서 SDL에 대한 연구를 진행했다. SDL에 속하는 구인으로는 다음과 같은 것들이 있다.

Scholars conduct empirical research on SDL across the globe. Some of the constructs investigated alongside SDL and reported here include 

• 호기심 curiosity (the desire forknowledge; Barnes, 1998); 
• 삶에 대한 만족 life satisfaction (the extent to which a person likes him/herself, is happy with the way he/she is leading his/her life, and is generally satisfied with the way he/she is; Brockett, 1982); 
• 동기 motivation (the degree to which an individual is self-motivated and achievement oriented; Livneh, 1988); 
• SDL능력 SDL competence (knowledge and skill required for SDL; Savoy, 2004); 
• 자기효능감 self-efficacy (judgment of a person’s own capability for successfully executing a course of action; Tuksinvarajarn, 2002); and 
• 지지 support (the ability to get independent assistance related to learning; Yu, 1998). 

추가로 연령이가 교육수준같은 demographic factor도 관계가 있다.

In addition, other demographic factors have been reviewed in relation to SDL, such as age and level of education.

목적과 가설 

Purpose and Hypothesis

SDL문헌들에서는 SDL척도와 구인간의 관계를 설명한 바 있다. 예컨대 호기심과의 관계는 0.1에서 0.79까지 다양하다. moderator가 존재할 가능성이 높다.

The SDL literature examines a wide range of relationships between SDL measures and other constructs. For instance, the variance of correlations between SDL and curiosity is .1 to .79. With such a large variance, it is possible that a moderator exists that would help explain such a large range (Hofmann, Gawronski, Gschwendner, Le, & Schmitt, 2005).

SDLRS가 워낙 많이 사용되어왔으므로, SDLRS와 다른 척도간의 비교를 하고자 한다. 

Since there was so much emphasis on using the Self-Directed Learning Readiness Scale (SDLRS; Guglielmino, 1978) in the literature, the investigation focused on those studies using the SDLRS vs. those studies using another form of measurement of SDL. The following hypothesis was tested: 

가설

H1: Measurement type moderates the relationship between SDL and (a) age, (b) curiosity, (c) education, (d) life satisfaction, (e) motivation, (f) SDL competence,(g) self-efficacy and (h) support.

SDL척도

SDL Measures Used

다양한 척도가 있었는데 대표적으로 다섯 개를 꼽음.

Although there were a variety of self-directed learning measures used in the literature, based on our meta-analysis, there were five measures used most often to assess SDL. 

• The SDLRS (Guglielmino, 1978) has been used more than any other instrument (800 times). 
• The Oddi Continuing Learning Inventory (OCLI; Oddi, 1984) comes in as a distant second in usage compared to the SDLRS (about 25% usage in comparison). 
• The number of hours spent using SDL based on Tough’s (1979) recommendation of at least seven hours in the previous six month period was used to measure SDL 78 times, the 
• BISL (Bartlett, 1999) was used 65 times, and 
• the number of learning projects used within a specific period was assessed 41 times.

Meta-Analytic Results

Table 1. Summary of Meta-Analytic Results

SDLRS 대 비-SDLRS

SDLRS vs. Non-SDLRS Moderator Results

Table 2. Moderator Results

결론

Conclusion and Discussion

SDL과 일부 구인과의 관계는 어떻게 SDL을 측정했느냐에 따라 달라진다. 따라서 age과 같은 요인들은 연령이 높아지면 SDL준비도가 높음을 뜻할 수도 있다. 그러나 다른 인적특성이나 다른 SDL요소인 자기주도학습에 사용한 시간, SDL활동의 수와 연관은 그만큼 강하지 않을 수도 있다. 이는 satisfaction, SDL competency, self-efficacy and support.에 대해서도 마찬가지다.

It is important to note that the relationships between SDL and some of the constructs used in the study do change depending on how SDL is measured. Therefore, factors such as age may implicate that learners will be more ready for SDL; however, as the data illustrate, age may not relate significantly to other measures of personal characteristics or other components of SDL such as the amount of time spent practicing SDL or the number of SDL activities completed, with the same strength. This is also true for life satisfaction, SDL competency, self-efficacy and support. 

그러나 curiosity, education, and motivation 에 대해서는 척도에 따라서 크게 달라지지 않았다. 즉 이 세가지는 어떻게 SDL을 측정하든 일관된 결과를 보여준다.

However, since relationships with curiosity, education, and motivation did not change significantly depending on the measurement instrument, it is possible that the constructs are important in both readiness for SDL and other components of measurement of SDL, such as use of SDL and time spent using SDL. Therefore, these three components yield consistent results when measuring SDL using different measures.

각 척도의 적절한 사용법 

Appropriate Uses of the Most Popular Measures

The measures of SDL should be selected based on the goals of the institution, the motivation for assessing SDL, the type of data collected and research questions presented. 

• For instance, if the goal of the research is to understand how likely employees are to adopt a SDL culture in the workforce or academic setting, then a personal characteristic measure may be more appropriate. 
• If the intent is to understand if employees/students use SDL and how effectively they are using SDL, then it might be more appropriate to assess behavioral measures such as how often they use SDL, what types and number of projects they use, SDL competence, and an output measure of performance.

각각이 장점이 다 다르다.

It should be noted that each of the measures has its own advantages. The most accurate forms of measurement can be taken through multiple assessments, and tell a richer story. This can be compared to diversifying a portfolio in the stock market to diminish risk.

Table 3. SDL Measurement Usage Suggestions

Appendix A Self-Directed Learning Measures

Self-Directed Learning Readiness - Cho & Kwon, SDLR-K-96 K-96 2005

THE MODERATING EFFECT OF THE SELF-DIRECTED LEARNING MEASUREMENT TOOL: A USER’S GUIDE

Stefanie L. Boyer, Diane R. Edmondson, and Andrew B. Artis

The relationship between self-directed learning (SDL) and other constructs varies depending on the measurement tool used in data collection and analysis. A meta-analysis of SDL research studies is used to explore the moderating effect of the measurement tool between SDL and constructs from adult education. This paper outlines the most commonly used measures to assess SDL and provides advice to researchers, trainers and employers on the appropriate tool given the goals of the assessment. Using multiple measures of SDL (contextual, behavioral and personal) along with output measures (job performance and learning effectiveness) will provide the most accurate assessment of SDL.

기술을 활용한 자기주도성 함양(IJSDL, 2013)

FOSTERING TECHNOLOGY AND SELF-DIRECTION: THE IMPACT ON ADULTS IN EDUCATION, BUSINESS, AND EVERYDAY LIFE

Naomi Boyer, Jeffrey Beard, Lila Holt, Joanne Larsen, Janet Piskurich, and George Piskurich

기술의 발전보다 21세기에 더 빠르게 발전한 분야는 없을 것이다. 하나의 예를 들자면, 1996년에는 총 4개의 인터넷 연결이 있었다. 2013년, 매 초 80개의 연결이 추가되며, 2014년 동안에는 초당 100개의 연결이 추가된다. 

It would be difficult to identify an area in which change has been more omnipresent and rampant in the 21st century than in the all-important area of technology. Just one telling example: in 1996 there were a total of four (4) internet connections on the planet. In 2013, 80 connections per second are being added, with 100 connections per second expected during 2014. By 2020, projections indicate that the number of internet connections will reach 50 billion--from zero to 50 billion, all during half of a human lifetime.

8세부터 18세까지의 2000명의 아이들을 대상으로 한 연구에서, 젊은 세대는 "미디어 멀티테스커"이다. 다양한 형태의 기술을 하루에 평균 7.5시간 이상 사용한다. 비록 연구가 젊은 세대에 맞춰져 있지만 가정에 그러한 최신기술이 존재하여 최소한 노년층도 이러한 기술에 노출되고 있다.

The findings, based on 2000 children from ages 8-18, are clear that young people today are “media multitaskers,” using various forms of technology an average of more than 7.5 hours per day. While the study focused on young people, the study reported an increase of technology presence in the home indicating adults are at least exposed, if not users, of these technologies.

최신 기술의 활용은 흥미와 필요에 의하지만 연령에 의해서 제한되지는 않는다. 많은 성인들이 필요가 생기면 기술에 적응한다. 최근의 보고서를 보면 71%이상의 성인이 일상적으로 인터넷을 활용하고 90%이상의 직장에서 이메일을 어떤 목적이든 사용한다. Horrigan은 성인들이 젊은 세대와 비슷한 속도로 - 특히 인터넷 접근에 대해서는 - 전자기기를 활용하고 있다고 보고했다.

It appears that technology use is primarily derived from interest and need and is not limited by chronological age (Horrigan, 2009). Many adults are required to use technology in the workplace and older adults often have to adapt to using technology as the need arises. Recent reports reveal that over 71% of adults use the Internet daily and over 90% of today’s workforce use email for some purpose (Rainie, 2010). Horrigan (2009) additionally discovered that adults are embracing the use of electronic devices at a rate comparable to young people - especially in relation to Internet access.

디지털 학습자

The Digital Learner

요즘 학생은 유치원부터 대학까지 컴퓨터 기술과 인터넷으로 가득찬 세상에서 자라왔다. 이 1980년대 이후 출생자들을 'Net Generation' 혹은 '디지털 네이티브'라고 부른다. Net Gen은 1980~1984년생을 지칭하며 약 9천만명에 달한다. Barnes Marateo, Ferris 등은 "이 세대는 디지털, 사이버 기술과 함께 자라난 첫 세대라는 점에서 특이하다"라고 했다. 

Most of today’s students (kindergarten to college) were raised in a world filled with computer technology and an Internet where information can be instantly obtained. This new generation of learners was born after 1980 and are commonly referred to as the Net Generation (Net Gen) or “digital natives” (Prensky, 2001). The Net Gen represents a population born between 1980 and 1994 and involves approximately 90 million people (Davidson & Goldberg, 2009; Johnson & Romanello, 2005; Notarianni, Curry-Lourenco, Barnham, & Palmer, 2009; Oblinger & Oblinger, 2005a; Sherman, 2006; Tapscott, 1998). Barnes, Marateo, and Ferris (2007) suggest that “[t]his generation is unique in that it is the first to grow up with digital and cyber technologies” (But Net Geners Learn Differently section, para. 3). Current college students have grown up in a digital world with the Internet and cell phones and communicate using various media options (Beyers, 2009; Davidson & Goldberg, 2009). These communication formats include texting, instant messaging, email, and social networking tools like Facebook and Twitter (Beyers, 2009; Horrigan, 2009; Lorenzo, Oblinger, & Dziuban, 2007).

미국 교육부의 직업 및 성인교육팀에 따르면 디지털 기술은 다음의 것을 포함해야 한다.

According to the U.S. Department of Education, Office of Vocational and Adult Education, digital technologies must be included: 

The use of digital technologies for learning both supports local efforts to educate adult learners and their teachers and extends educational opportunities to reach new groups of students. The thoughtful integration of digital technologies into the traditional scheme of education and their use to develop new ways of learning is necessary to ensure students have the tools to thrive in a complex and rapidly changing technological society. (Technology and Distance Learning, 2008)

자기주도학습

Self-Directed Learning 

많은 사람들이 SDL을 정의했다. 그리고 일부 정의는 '사람들이 자신이 바라는대로 정의하는 바람에 비뚫어졌'다. Owen은 이러한 SDL 정의의 왜곡을 "무계획적인 명명"이라고 말하며, 이 때문에 같은 개념을 다양한 이름으로 부르게 되었다고 했다. Carre는 20개 이상의 서로 다른 SDL에 대한 이름을 찾았고, Hiemstra는 200개 이상의 variation을 찾았다. 

Many have defined self-directed learning (SDL), and some of these definitions may have "been skewed by those who choose to define it as they wish" (Brookfield, 1986, p. 18). Owen (2002) attributes a distortion of the SDL definition to "haphazard nomenclature" (p. 1) leading to many names for the same general concept. Carré (1994) found well over 20 different names used for SDL, while Hiemstra (1996) discovered over 200 variations in conference proceedings. Self-direction in adult learning has been labeled as 

• self-teaching, 
• self-planned learning, 
• inquiry method, 
• independent learning, 
• selfeducation, 
• self-instruction, 
• self-study, 
• self-initiated learning, and 
• autonomous learning (Owen, 2002). 

이 모든 이름들은 '한 사람의 고립된 학습'이라는 인상을 주나 Knowles는 SDL은 주로 다양한 종류의 도우미(교사, 튜터, 멘토, 동료)와 함께 이뤄진다고 했다. SDL은 스스로의 학습의 방향을 정하는 개인과 그 과정에 포함되는 다른 사람들을 포함한다.

All of these labels give the impression of one person learning in isolation, whereas Knowles (1975) wrote that SDL usually takes place in association with various types of helpers such as teachers, tutors, mentors, and peers. SDL can involve an individual directing his or her own learning with other people involved in the process. 

어떤 사람들은 SDL을 자율학습이라고 정의하는데, '자기주도'는 혼자서 공부하는 것 만으로 생각되어서는 안된다. Brockett과 Hiemstra는 다음에 대해 SDL의 신화라며 대해서 이렇게 이야기했다. "SDL은 고립되어 일어나는 것이라는 것은 잘못된 신화이다. 진정으로 자기주도성의 효과를 알기 위해서는 교수법 차원에서, 그리고 개인의 특성 차원에서 SDL이 발생하는 사회적 환경을 인식하는 것이 중요하다"

While some have defined self-directed learning as autonomous learning, selfdirection should not be perceived only as learning by oneself. Brockett and Hiemstra (1991) caution against the myth that SDL “takes place in isolation. In order to truly understand the impact of self-direction, both as an instructional method and as a personality characteristic, it is crucial to recognize the social milieu in which such activity transpires" (p. 32).

사람은 가장 효과적인 방법을 선택하면서, 그것이 다른 사람에게도 가장 잘 맞는 방법일거라고 생각한다. 그러나 어떤 생각이나 개념을 (특히 교육학에서는) 만병통치약으로 생각해서는 안된다. SDL은 학습을 촉진하는 유일한, 혹은 최고의 방법이 아니다. 반대로 학습자의 학습에 대한 개인적 책임을 강조하는 것처럼, SDL은 어떤 맥락인지 어떤 목표인지에 따라서 함양할 가치가 있고 고려할 가치가 있는 것이다.

Humans adopt methods that are most effective for use and often assume that what works for one must be the best approach for others. However, as with any idea or concept (especially in education), one must not be quick to proclaim a “one size fits all” strategy. SDL is not the “only” or “best” way to facilitate learning for self or others; however, as it pertains to learners assuming personal responsibility for their own learning, SDL is worthy of cultivation and consideration dependent upon the context and objective.

Brockett과 Hiemstra는 SDL이 성공적인 학습으로 도달하는 유일한 접근법이 아니라는 것을 명확히 했다. 다만 교육자가 학습자들이 학습에 개인적인 책임과 참여를 하도록 이 방법을 선택할 수는 있다. 어떤 학습에 들어설 때 자기주도성의 수준이 성공의 지표가 되지 못한다고 했다. 그러나 성인교육자는 성인들이 "학습에 대한 개인의 책임"을 가질 수 있도록 해야한다.  

Brockett and Hiemstra (1991) make it clear that SDL is not the only approach that leads to successful learning, but one that educators of adults may choose in order to enable learners to assume personal responsibility and involvement in their own learning. They go on to explain that the level of self-direction demonstrated by a learner upon entering a learning experience is not necessarily indicative of success; however, the adult educator can play a role in assisting adults to “assume personal responsibility for their own learning” (p. 27). In this article SDL will be defined as Knowles (1975) posited:

자기주도성을 통한 기술 활용

Learning to use Technology Through Self-Direction: Learning Technology Itself

새로운 기술이나 기기의 사용을 익힐 때는 직접 경험이 중요하다. Dewey는 "직접 경험하는 과정과 교육 사이에는 매우 가깝고도 필수적인 관계가 있다"라고 했다. 학습자가 직접 경험을 해야 한다는 생각은 새로운 것은 아니지만, 어떤 주제가 '테크놀로지'에 대한 것일 때는 더욱 그러하다. Jarvis는 "모든 학습은 경험과 함께 시작한다"라고 했고, Linderman은 "성인교육에서 최고의 가치는 학습자의 경험이다"라고 했다.

Learning to use new applications or electronic devices involves the user’s hands-on experience. Dewey (1938) suggested “there is an intimate and necessary relation between the process of actual experience and education” (p. 20). The idea of the learner gaining actual experience with a topic of study is not new, but may be more desirable when the subject is technology. Jarvis (1987) posited “all learning begins with experience” (p. 16) and Lindeman (1926) argued that the “highest value in adult education is the learner’s experience” (p. 6).

SDL접근법은 교육 세팅이 학생들이 새로운 테크놀로지를 사용하는 것을 배울 수 있도록 되어 있을 때 좋은 결과를 가져온다. Clinton과 Reiber는 SDL접근법을 석사 프로그램에서 사용하였다.

The SDL approach is being used with good results in educational settings where students are learning to use technology. Clinton and Rieber (2010) use an SDL approach in an instructional technology master’s program through a series of studio courses. The program uses an SDL approach that Candy (1991) refers to as assisted autodidaxy (self- education with instructor guidance, e.g., independent study).

의학교육에서의 사례 

Case Example: Medical Education

• The 1984 Association of American Medical Colleges (AAMC) Physicians for the Twenty-first Century: Report of the Project Panel on General Professional Education of the Physician and College Preparation for Medicine acknowledged that advances in scientific knowledge and technology were already occurring at such a rate that doctors for the new century must learn throughout their professional lives rather than simply master current information and techniques (AAMC, 1984). Recommendations were made that medical students should be adequately prepared for active, independent, self-directed learning; and that medical schools should provide opportunities for development of learning skills and evaluate students’ abilities to learn independently. 
• Almost 10 years later, the AAMC Assessing Change in Medical Education-The Road to Implementation (ACME-TRI) report further recommended that “faculty members’ first goal should be to foster their students’ life-long learning by helping them to develop their learning skills” (AAMC, 1993). 
• The Liaison Committee on Medical Education (LCME) was formed as the nationally recognized accrediting agency for medical education programs in the U. S. and Canada. LMCE accreditation standard ED-5-A states, “A medical education program must include instructional opportunities for active learning and independent study to foster the skills necessary for lifelong learning (LCME, 2010).

Changes in medical education focused on the goal of meeting accreditation standards and graduating medical students who are skilled learners have fostered development of a number of novel medical school curriculum models. These models include those that are strictly problem-based (Blumberg, 2000) or clinical presentation- based (Mandin, 1997), plus an increasing number of hybrid approaches. 

• In the problem- based curriculum students read medical cases, set learning issues and independently fulfill the self-prescribed learning necessary to fully understand the aspects of each case with a learning facilitator serving only as a guide. 
• In contrast, the clinical presentation-based curriculum relies more on experts to model and encourage inductive rather than deductive reasoning approaches toward clinical diagnoses.

Teachers and learning facilitators who foster self-directed learning in undergraduate medical education use online resources in a wide variety of ways. 

• In a problem-based learning curriculum, a study was designed to explore why only a subset of medical students used the available online resources to fulfill their self-prescribed learning needs (Piskurich, 2004). We asked the students to describe experiences that they felt had made them better online learners. Interestingly, their comments included many of the behaviors that have been proposed for the improvement of self-directed learning (Guglielmino & Guglielmino, 2004).
• Even for the more expert-driven clinical presentation-based medical school curriculum model, the effort to meet LCME accreditation standards is resulting in a push to move lecture content out of the lecture hall and to use class time for more active learning; thus more medical schools are embracing “flipped-classrooms” where various digital formats are used to move content previously delivered as in-class lectures to homework delivered online, thus freeing up class time for simulation and application exercises (Prober & Heath, 2012).

단점: 의과대학생이 받아들이기를 거부한다. 

One drawback is that medical students who relied heavily on lectures delivered in lecture halls to attain the grades and standardized test scores to gain acceptance into medical school are initially reluctant to adopt these more self-directed approaches to learning. Initial resistance to self-directed learning has long been recognized (Long, 1994) and can result in poor student perceptions of faculty who employ teaching-learning interactions that foster self-direction. 

임상표현 모델에서 ARS 시스템의 활용, 성공적.

In the clinical-presentation model, audience response systems have been successfully utilized to give students a choice in the design of upcoming classes (Piskurich, 2012). Providing this opportunity for learner input into the class design and role of the learning facilitator had a positive impact on student level one evaluations, even when the sessions were delivered in the “flipped classroom” format.

AAMC (Association of American Medical Colleges). (1984). Physicians for the twenty- first century: Report of the project panel on the general professional education of the physician and college preparation for medicine. Journal of Medical Education, 59, 1-208.

AAMC. (1993). Educating medical students: Assessing change in medical education-the road to implementation (ACME-TRI report). Academic Medicine, 68, S33.

Piskurich, J. F. (2012) Fostering self-directed learning in medical school: When curricular innovation is not enough. International Journal of Self-Directed Learning, 8(2) 44- 52. Retrieved from http://sdlglobal.com/journals.php

Prober, C. G., & Heath, C. (2012). Lecture halls without lectures: A proposal for medical education. New England Journal of Medicine, 366(18), 1657-1659.

FOSTERING TECHNOLOGY AND SELF-DIRECTION: THE IMPACT ON ADULTS IN EDUCATION, BUSINESS, AND EVERYDAY LIFE

Naomi Boyer, Jeffrey Beard, Lila Holt, Joanne Larsen, Janet Piskurich, and George Piskurich

Technology has become the backbone of everyday life and is integral to our daily process. Whether the word “technology” relates to the technical infrastructure such as networks, Internet, or software programs, or the tools that we use to be productive, communicate, and learn, matters not; in all of these areas, the technological world requires individual self-direction and adaptability to remain current. Through case examples, the intersections of technology, self-directed learning, and everyday life are presented to portray the implications of technology for adult learning and development. While technology alone is not a panacea for the facilitation of learning, the coupling of self-direction with technology does provide the opportunity to fundamentally alter the way in which individuals perceive, construct, and engage with learning activities.

비공식적 학습용 웹사이트 분석(IJSDL, 2014)

ANALYZING THE HUMAN LEARNING AND DEVELOPMENT POTENTIAL OF WEBSITES AVAILABLE FOR INFORMAL LEARNING

Minkyoung Kim, Eulho Jung, Abdullah Altuwaijri, Yurong Wang, and Curt Bonk

Despite the existence of overlap, we defined each of the six categories distinctly:

1. Language learning 

resources use technology-aided language learning with an integration of sound, voice interaction, text, video, and animation. It empowers self-paced interactive learning environments that enable learners to achieve learning outcomes without being restricted to place or time. Often, such environments involve numerous opportunities for participation users and multiple methods for motivating their success. Online language learning often entails high levels of self-directed and reciprocal learning or supporting peer learning (see Ehsani & Knodt, 1998)

2. Outdoor and adventure learning 

is a hybrid online educational environment that provides students with opportunities to explore real-world issues through authentic learning experiences within collaborative online learning environments. Inquiry-based learning including teamwork, authentic data analysis, and project-based learning is encouraged (see Doering, 2006). 

3. Social change/global 

resources seek to educate and inform people about issues and needs relating to social change, including poverty, hunger, AIDS, civics, the environment, etc. Technology is often used to create innovative ways to spread social good and access to learning worldwide. It is also used to empower and inspire people for the right cause.

4. Virtual education 

refers to learning environments where teacher and student are separated by time or space, or both. Course delivery can be through course management applications as well as various multimedia and Web 2.0 tools. Virtual education may be managed by organizations and institutions that have been created through alliances and partnerships to facilitate teaching and learning. Some virtual education websites provide learner services such as advising, learning assessment, and program planning (see Farrell & the Commonwealth of Learning, 2001). Our categorization and ratings are limited to virtual education resources that are available to individual learners at no cost.

5. Learning portals 

are centralized learning centers or repositories that contain an aggregation of educational information on a topic, often current or continually updated. Learners explore according to their own interest, time, and space. Learning portals support user and context learning, and are less centered on administration of that content and the results of the learning. 

6. Shared online video 

includes any educational video (YouTube or other webstreamed videos) that can be watched or shared. Some such sites offer syndicated programming and professional documentaries or filmmaking, whereas others are supported by lay people. These sites often allow for interaction via comments and annotation. They often allow for downloading of content.

Table 1. Definitions of Evaluation Criteria

Table 3. Top 25 Rated Learning Websites

Table 4. Top 25 Websites According to Informal Learning Criteria and Category

ANALYZING THE HUMAN LEARNING AND DEVELOPMENT POTENTIAL OF WEBSITES AVAILABLE FOR INFORMAL LEARNING

Minkyoung Kim, Eulho Jung, Abdullah Altuwaijri, Yurong Wang, and Curt Bonk

The advancement of learning technology in recent decades has broadened the possibilities for online learning in both formal and informal settings. This research was designed to reveal the essential characteristics of successful online resources and technology tools that are important resources for self-directed learning. Over the span of a year, a team of researchers collected and analyzed 305 informal learning websites and virtual education websites available at no cost to individual learners. The websites were categorized into the following six subject domains: language learning, outdoor and adventure learning, social change and global learning, virtual education, learning portals, and shared online video. Content analysis was employed to evaluate the 305 websites using eight evaluation criteria: content richness, functionality of technology, extent of technology integration, novelty of technology, uniqueness of learning environment/learning, potential for learning, potential for lifechanging impact, and scalability of the audience. The six categories or types of informal learning were then compared by applying the eight criteria.

의과대학 교육과정 중 자기주도학습 역량 향상을 위한 현실적 전략(IJSDL, 2014)

PRACTICAL STRATEGIES TO PROMOTE SELF-DIRECTED LEARNING IN THE MEDICAL CURRICULUM

Dirk Morrison and Kalyani Premkumar

근거중심의학의 저명한 선구자인 David Sackett은 SDL이 왜 다급한지 다음과 같이 요약했다.

David Sackett, a well-known pioneer of evidence-based medicine, famously summed up one of the major reasons that development of self-directed learners is increasingly being recognized as an urgent need: 

당신이 의과대학에서 배운 것중에 절반은 졸업 후 5년 이내에 사라지거나 틀렸음이 증명될 것이다. 문제는, 거기에 해당할 것들이 무엇인지 알려줄 수 있는 사람이 아무도 없다는 것이다. 따라서 가장 먼저 배워야 할 것은 스스로 학습하는 방법이다.

Half of what you'll learn in medical school will be shown to be either dead wrong or out of date within five years of your graduation; the trouble is that nobody can tell you which half -- so the most important thing to learn is how to learn on your own. (Cited in Daily & Landis, 2014, p. 2066)

Daily, J. A., & Landis, B. J. (2014) The journey to becoming an adult learner: From dependent to self- directed learning. Journal of the American College of Cardiology, 64 (19), 2066-2068. Retrieved from http://content.onlinejacc.org/article.aspx?articleID=921687

SDL이 평생학습의 중요한 원칙이라는 것과 평생학습이 보건의료직에 대해 일반적으로 기대되는 점이라는 것은 자명해보인다.

It seems intuitively obvious that SDL is an important principle of lifelong learning (Candy, 1991) and that lifelong learning is a general expectation for the health professions;

SDL의 가치는 높이 평가받지만, 적어도 원칙에 있어서 어떻게 UME, GME, CPD라는 의학교육 연속체에서 SDL을 증진시키고 실현할 것인가에 대해 다룬 문헌은 거의 없다. Premkumar의 최근 종단연구에서 University of Saskatchewan’s College of Medicine 학생들은 SDLRS나 LPA로 측정했을 때 UME동안 입학때에 비해서 자기주도학습성이 떨어졌다.

While SDL is valued, at least in principle, along the medical education continuum (undergraduate, postgraduate and continuing professional education), there is a clear lack of documentation regarding how to promote and actualize SDL. A recent longitudinal study (Premkumar et al., 2013) of undergraduate medical students at the University of Saskatchewan’s College of Medicine assessing changes in self-directed learning readiness, as measured by the Self-Directed Learning Readiness Scale (SDLRS) or Learning Preference Assessment (Guglielmino, 1978; Guglielmino & Associates, 2010) indicated a significant drop during undergraduate medical training, as compared to measures of SDL readiness at admission.

의과대학에 들어온 학생이 일반적인 학생집단에 비해서 SDLRS가 높다는 점을 비추어보면, 의과대학 교육과정의 특정 요소들(인지적 과부하, 평가유형, 시간 부족) 등이 초반의 높은 자기주도성을 하락시키는 것으로 추정된다.

Given that entering students of health professions have been shown to have higher SDLRS scores as compared to the general student population (Premkumar et al., 2013), it is speculated that specific factors in the traditional orientation and structure of the medical curriculum (e.g., cognitive overload, assessment types, lack of time, etc.) may erode an initial positive orientation toward self-directed learning.

Reversing the Trend: Integrating SDL principles and Strategies Into the Curriculum

전략 1: SDL에 대한 오리엔테이션 제공

Strategy 1: Provide an Orientation to SDL

학생과 교수 모두 SDL기술과 역량을 발휘하고 있으나, 그렇게 이해하고 있지는 않을 수 있다.

It is likely that many students and faculty exercise skills and competencies of SDL but may not understand them as such

교육과정 시작시에 SDL의 목표와 원칙에 대해서 명확히 설명해주기 위한 노력을 충분히 들여야 한다.

어떻게 SDL이 학생들에게 기대되고 있으며, 이것이 전체 교육과정에서 중요한 점이라고 명확히 설명해주는 것, 그리고 일관된 교육 주제 등이 이러한 오리엔테이션을 잡는데 중요할 것이다.

Clearly explaining how SDL is an expectation of all students and that it is an integral part of the overall curriculum, a consistent pedagogical theme, will be an important part of such an orientation (Daniels, 2011).

전략 2: 학습자의 SDL준비도와 기술을 확인하라.

Strategy 2: Identify Individual Learner's SDL Readiness and Skill Level

SDLRS가 있다.

The SDLRS instrument,

Grow의 네 단계 모델을 활용하는 방법도 있다.

The application of Grow's (1996) Staged Self Direction Model (stage 1: low self-direction - stage 4: high self-direction) may also provide some insight here,

SDL준비도는 상황이나 교육내용에 따라서 달라질 가능성이 높다. 학습자의 SDL준비도를 알고 거기에 맞춰서 교육을 조절해야 한다. 예컨대 Dynan Cate rhee는 SDLR 점수에 따라 구조화된 혹은 비구조화된 학습환경으로 학습자를 구분하고 두 집단 모두에서 SDLRS 점수가 상승함을 확인했다.

SDL readiness will likely vary based on situation and topic. It would be important to understand learner readiness to engage with SDL and make adjustments to the curriculum. For example, Dynan, Cate, and Rhee (2008), in reviewing a research study that grouped learners in structured and unstructured learning environments based on their SDLR scores found that the SDLRS scores increased in both groups.

전략 3: SDL역량의 발달을 명확히 하고 촉진하라

Strategy 3: Clarify and Promote the Development of SDL Competencies

Weimer가 지적한 바와 같이 SDL에 필요한 핵심 역량은 다음을 포함한다. 

As Weimer (2010) points out, a core set of competencies for SDL would include the ability for learners to “

• assess the demands of the task, 
• evaluate their own knowledge and skills, 
• plan their approach, 
• monitor their progress, and 
• adjust their strategies as needed” (p. 5). 

다른 것으로는..

Other competencies would include: “

• proficiency in assessment of learning gaps, 
• evaluation of self and others, 
• reflection, 
• information management, 
• critical thinking, and 
• critical appraisal” (Premkumar et al., 2013).

이러한 기술을 연습할 분명한 지침과 기회를 전 교육과정에 걸처 제공하는 것이 중요하다. 또한 Wimer는 연구를 살펴보면 SDL skill은 직접적 교육보다는 우연에 의해서 향상되며 메타인지 기술을 갈고닦을 필요가 있음을 언급했다.

Explicitly providing instruction and opportunities to practice these skills, across the curriculum, will be critical if SDL is to be successfully integrated. In addition, Weimer (2010) states that research indicates SDL skills are developed much more efficiently by direct instruction than by happenstance, and includes the need to hone metacognitive skills.

• Assess the task by being more explicit than you may think necessary. 

• Evaluate how well they’re equipped to do the task by providing opportunities for self-assessment early and often. 

• Plan an appropriate approach by first implementing a plan you’ve provided and then by creating their own plans. 

• Apply selected strategies and monitor progress by having students do guided self-assessments.

• Adjust their strategies by encouraging them to analyze the effectiveness of what they have done.

전략 4: 자신의 관심사를 추구할 기회를 제공하라

Strategy 4: Provide Opportunities to Pursue Own Interests

학습자가 학습과제를 다양한 전략과 다양한 방법으로 접근하게끔 장려하는 것은 중요하나, 이에 못지 않게 학습자들이 스스로의 관심사를 능동적으로, 체계적으로 쫒도록 하는 것도 중요하다. 이는 SDL을 학습과 교육의 구조 속에 넣는 것으로 달성될 수 있다.

While it is important to encourage learners to approach a task in different ways using different strategies, it is also critical that learners actively and methodically pursue their own interests. This may be achieved by framing SDL in the way learning and instruction is organized.

현재 의과대학은 주로 4학년때 관심있는 자신의 전공과나 분야 경험을 쌓을 수 있다. 예컨대 학생들은 구체적인 관심영역을 개별 코스에서 쫒을 수 있다. 이 SDL과정은 적절한 평가 요소를 포함시켜 공식화 될 수 있다.

Currently, medical students are usually given opportunities in their senior years to pursue experiences in medical specialities or areas that are of interest to them However, more and more varied opportunities need to be provided throughout the curriculum. For example, students can be given opportunities to pursue specific topics of interest within individual courses; this SDL process needs to be formalized with incorporation of an appropriate assessment component.

학습자가 자신의 문제를 스스로 만들어서 학습 전략을 활용할 수 있는 환경을 제공하는 것은 논리적으로 합당할 뿐만 아니라 authenticity와 학습자가 심화 학습을 위해 참여할 수 있는 길을 만들어준다. 

As often as is reasonable, providing strategies and learning contexts whereby learners formulate their own problems (individual or collective) to be researched and solved, will provide another layer of authenticity and, potentially, increase learner engagement and deeper learning.

전략 5: 협력적 학습을 활성화시키라

Strategy 5: Activate Collaborative Learning

SDL이 많은 경우 자율학습과 동일한 의미로 사용되지만, 이는 사실이 아니다. 비슷한 생각을 하고 비슷한 동기를 갖는 동료들과 함께 공부하는 것은 SDL의 원칙에 위배되는 것이 아니다. 팀바탕 학습의 다양한 기회를 제공하고, 동료끼리 가르치고 프로젝트나 문제를 기반으로 한 그룹 학습은 개개인의 학습 전략과 그룹 협력적 프로세스를 통하여 SDL의 원칙을 더 강조할 수 있다. 

While SDL is seen by many as synonymous with autonomous learning (insinuating a “learner learning alone”), nothing is farther from the truth: opportunities to learn with other like-minded, like-motivated peers is not antithetical to the principles of SDL. Providing multiple and varied opportunities for team-based learning, peer teaching and project or problem-based group learning would underscore the fact that the principles of SDL can be actualized via individual learner strategies and collaborative group processes.

의학 교육과정의 심화 이해를 달성하기 위해 Barrett과 Moore는 학습자들이 문제에 깊이 관여하면서 아이디어를 공유하고, 다양한 관점과 해석을 접하고, 공통의 의미를 향유함으로서 능동적으로 지식을 생산, 재생산하는 것이 필요하다고 주장하였다. 이는 상호작용/협력/의사소통을 통해서 가능하다.

If deep understanding of the medical curriculum is to be achieved, Barrett and Moore (2011) argue for the need to create environments and processes whereby learners actively create and re-create knowledge together, by sharing ideas, confronting divergent views and interpretations, embracing shared meanings and by deeply engaging with learning problems in “interactive, collaborative, communicative ways” (Armitgage, 2013, p. 5).

전략 6: 의미있는 성찰을 장려하기

Strategy 6: Encourage Meaningful Reflection

따라서 학습자들이 자신의 SDL에 대해서 능동적, 비판적으로 성찰하려면 개념적, 조작적 프레임워크를 제공하여 평가 틀로 활용해야 한다. 이 능동적 성찰의 최종 목표...

It will be important, therefore, to provide a conceptual and operational framework, an evaluative scaffold, if you will, whereby the learner can actively and critically reflect on their SDL. End goals of this active reflection might be to 

• look for insights into how one learns best, 
• evaluate and then make adjustments in personal learning strategies, 
• pursue promising avenues of investigation and interest, 
• reflect on action (i.e., retrospective analysis) and 
• reflect in action (a mindfulness while one is executing an action) (Schon, 1983).

Day One이나 Evernote, e-portfolio 등을 사용할 수 있다.

application journal such as Day One (Bloom Built, 2014) or Evernote (Evernote Corp., 2008) 

Regularly annotating e-portfolio entries

전략 7: SDL을 통합시키기 위해서 학생 평가를 바꾸라

Strategy 7: Alter Student Assessment To Integrate SDL

성찰 없이는, MCQ, 빈찬 캐우기, 단답형 등과 같은 평가방식은 효율성은 높을지 모르나 SDL의 기회는 거의 제공하지 않는다. 더 정확히는 자기주도적 평가가 안된다.

With a little reflection, it is clear that multiple choice, fill-in-the-blanks, short answer and other such assessment tools, while affording efficiencies (e.g., machine- graded), offer little to create opportunities for SDL, or, more accurately, self-directed assessment.

Driessen 등은 포트폴리오를 성공적으로 사용하는 조건을 언급했다.

Driessen et al. (2005) outline some of the necessary conditions for the successful use of portfolios in medical education; what is especially important in this study is that they were able to show that “portfolios are a potentially valuable method of assessing and developing students’ reflective skills in undergraduate medical training…” (p. 1230). If this method is to be used to encourage and support SDL, then necessary conditions need to be fulfilled, including: 

• “an appropriate portfolio structure, 
• an appropriate assessment procedure, 
• the provision of enough new experiences and materials, and 
• sufficient teacher capacity for adequate coaching and assessment” (Driessen et al., 2005, p. 1230).

전략 8: SDL을 진행할 시간을 주라

Strategy 8: Make Time Available for the Processes of SDL

Goodlad는 교수자는 학교의 상황을 만들고, 학교의 상황에 따라 만들어진다. 시간은 사용할 수 있는 가장 중요한 학습 자원으로서, 시간을 어떻게 사용하는가가 학습 기회의 차이를 가져온다. 따라서 시스템은 이 소중하고 제한된 자원의 활용(또는 오용)되는 것에 영향을 주며, SDL활동과 절차를 위한 시간을 배분하기 위해서는 Radical한 사고의 전환이 필요하다.

Goodlad (1984) points out, “teachers both condition and are conditioned by the circumstances of schools...; time is virtually the most precious learning resource they have at their disposal…[and]...differences in using time create inequities in opportunity to learn” (pp. 29-30). The system, then, perpetuates the use (or misuse) of this precious and limited commodity; a radical shift in thinking will need to occur in order to press for allocations of time for SDL activities and processes. 

이러한 주장을 할 때 '단순히 시간을 더 달라'라고 주장하는 것이 아님을 강조하는 것이 중요하다. 그보다 Goodlad의 말을 활용하자면, "우리는 시간을 더 달라고 주장하는 것을 멈추어서는 안된다. 나는 언제나 많은 시간을 무익하게 쓰느니 적은 시간을 잘 사용하는 것을 선택해왔다. 시간을 늘리는 것은, 사실상, 어떻게 그 시간을 사용할 것인가에 대한 개선이 동시에 있지 않다면 오히려 생산성을 저해시킬 뿐이다."

It is important, when making such arguments, to underscore that we are not arguing for simply more time but echo the sentiments of Goodlad (1984), who states: We must not stop with providing only time. I would always choose fewer hours well-used over more hours of engagement with sterile activities. Increasing [time] will, in fact, be counterproductive unless there is, simultaneously, marked improvement in how time is used. (p. 283)

전략 9: 대화 학습법을 핵심 방법으로 강조하기

Strategy 9: Emphasize Dialogical Learning as a Core Method

대화의 힘이 고관여의 심화학습의 줏추돌임은 이미 보여진 바 있다. Armitage는 이렇게 주장했다. 대화는 학생과 교사가 아는 것과 다시 아는 활동을 통해 서로 모아준다. 교사에게 고정되어있던 지식을 정적으로 전달하는 것 대신, 대화는 의식화 운동(conscientization)의 과정을 통해 지식을 칠천할 것을 요구하며 재생산한다.

The demonstrated power of dialogue as the cornerstone for engaged and deep learning seems clear. Armitage (2013) asserts: ...Dialogue brings together the teacher and the student in the joint act of knowing and re-knowing the object of study, where instead of transferring knowledge statically, as a fixed possession of the teacher, it demands and recreates acts of knowledge through the process of conscientization. (p. 7)

현재의 정보통신기술을 활용하여 실시간이 아니어도 학습자는 토론을 할 수 있다.

Rather, harnessing current information and communication technology tools (e.g., smart phones), learners would be able to extend the discussion not only in real time,

전략 10: ICT를 사용하라

Strategy 10: Provide and Train Learners in the Use of Information And Communication Technologies (ICT) Tools to Enhance SDL Strategies

전략 11: 학습자가 정보를 관리하고 평가할 수 있게 하라.

Strategy 11: Help Learners to Manage and Evaluate Information

정보의 신빙성과 관련성을 평가하는 기술이 필요하다.

Honing these skills to include critical appraisal of the trustworthiness (of sources, validity, etc.) of relevant and targeted information resources will prepare medical students for the realities of being a physician in the 21st Century (Cronin et al., 2014).

전략 12: 교수개발이 필요하다

Strategy 12: Train Faculty in SDL

성공적인 SDL을 도입하려면 교수들의 참여가 필수적이다. 처음에는 약간의 긍정적인 평가에 지나지 않을 수 있다.

The most critical factor in the successful implementation of an innovation such as the integration of SDL across the medical curricula will be medical faculty buy-in, which, initially, may be little more than positive regard, or a general agreeableness to the idea.

SDL에 대한 아이디어가 도입되기 시작하면, 실험과 평가, 긍정적 평가를 통해서 근거를 제시해야 하고, 그 다음에는 기관 전체의 교수들에게 SDL전략의 설계, 전달, 평가에 대한 훈련을 통해 효과적인 도입이 가능하다.

Once the idea of SDL takes root, providing concrete evidence of its efficacy via trials, evaluations, positive assessments, etc., then broaching the next steps, namely, taking an integrated approach to SDL and moving well beyond buy-in from medical faculty to an institution-wide commitment to training in the design, delivery and evaluation of SDL strategies will ensure effective implementation.

It is important to underscore that many of the SDL learning strategies described above, especially those that are skills, knowledge, attitudes-based, are not mutually exclusive; it is likely that these would be used in an ever-changing constellations or combinations, when needed and as the particular SDL challenges dictate. The point here is that the medical student uses what she needs, when she needs it; and applies these in the ways she needs to, to direct and be in control of her own learning.

It is clear that not all of the suggestions provided above could immediately, or easily be adopted and integrated by any particular medical education faculty and curriculum. However, moving the established medical education system toward a greater emphasis on self-directed learning principles and practices, even if incrementally, would be a step in the right direction and yield positive results as we prepare the doctors of tomorrow for lifelong learning.

Grow, G. O. (1991/1996). Teaching learners to be self-directed. Adult Education Quarterly, 41 (3), 125-149. Expanded version available online at: http://www.longleaf.net/ggrow

PRACTICAL STRATEGIES TO PROMOTE SELF-DIRECTED LEARNING IN THE MEDICAL CURRICULUM

Dirk Morrison and Kalyani Premkumar

Ideally, the 21st century physician, as a lifelong learner, is empowered by a deep understanding and actualized skills of self-directed learning (SDL). While SDL is an intuitively valued element of most medical education curricula, unless SDL is explicitly valued and spirally integrated across the curriculum, it is unlikely to be acquired as a core learning skill set by undergraduate medical students. In this paper, we outline a coherent set of practical strategies to promote and sustain SDL in the undergraduate curriculum. The implementation of these teaching and learning strategies may reverse a trend discovered in one medical school (i.e., a drop in student SDL readiness), by providing a teaching and learning environment in which the principles of SDL can be fully supported and actualized.

자기조절학습과 자기주도학습: 왜 서로 의사소통이 안될까? (IJSDL, 2014)

SELF-REGULATED AND SELF-DIRECTED LEARNING: WHY DON’T SOME NEIGHBORS COMMUNICATE?

Laurent Cosnefroy and Philippe Carré

지난 50년간 서양권 국가에서 등장한 평생학습과 자율적 지식노동자에 대한 유망한 비전과 함께, 성인교육, 직업교육, 교육심리와 관련된 분야의 문헌에서 자기학습 개념에 대한 관심이 매우 높아졌다. 약 20년 전에 Carre는 성인교육 문헌에서 자율학습과 관련된 15개 이상의 언급들을 찾아냈다.

Parallel to the promising visions of lifelong learning and the autonomous knowledge worker that have emerged in most Western countries over the last 50 years, the literature in the relevant fields of adult education, vocational training and educational psychology has evidenced a striking intensification of interest in self- learning concepts. More than 20 years ago, Carré (1992) conducted an initial search which produced no less than 15 notions used in the adult education literature in relation to autonomous learning: 

• autonomous learning, 
• independent learning, 
• self- directed learning, 
• self-managed learning, 
• self-organized learning, 
• self-regulated learning, 
• self-determined learning, 
• self-planned learning, 
• self-initiated learning,
• self-learning, 
• self-education, 
• self-instruction, 
• self-teaching, 
• autodidaxy, and 
• autodidactic learning.

이 중에 가장 많이 나타나는 것은 SDL과 SRL이다. 

보통 사람들에게 SDL과 SRL은 거의 동의어처럼 보인다. 심지어 교육심리 분야의 학자들도 SDL과 SRL은 문헌에서 서로 interchangeable하게 사용되기도 한다.

Definitions and Scope Analysis For the layperson, there is little doubt that, semantically speaking, SDL and SRL are close neighbors and could be considered as synonymous. Even scholars in educational psychology have suggested that the terms self-directed learning and self-regulated learning have often been used interchangeably in the literature (Loyens, Magda, & Rikers, 2008).

SDL의 가장 널리 사용되는 개념적 토대는 Knowles의 것이다.

A widely accepted conceptual foundation of SDL is Knowles’ (1975) definition: 

In its broadest meaning, self-directed learning describes a process in which individuals take the initiative, with or without the assistance of others, in diagnosing their learning needs, formulating learning goals, identifying human and material resources for learning, choosing and implementing appropriate learning strategies, and evaluating learning outcomes. (p. 18)

20년 후에 Long은 다시 이렇게 말했다.

Twenty years later, Long (1991) concurred: 

“I define self-directed learning as a personally directed purposive mental process usually accompanied and supported by behavioral activities involved in the identification and searching out of information” (p. 15).

거의 동시에 Zimmerman은 이렇게 말했다.

At about the same time, Zimmerman (1989) proposed: 

In general, students can be described as self-regulated to the degree that they are metacognitively, motivationally, and behaviorally active participants in their own learning process. Such students personally initiate and direct their own efforts to acquire knowledge and skill rather than relying on teachers, parents, or other agents of instruction. To qualify specifically as self-regulated in my account, students’ learning must involve the use of specified strategies to achieve academic goals on the basis of self- efficacy perceptions. This definition assumes the importance of three elements: students’ self-regulated learning strategies, self-efficacy perceptions of performance skill, and commitment to academic goals. (p. 329)

Zimmerman의 SRL에 대한 모델이 아마 가장 유명할 것이다 다른 것도 있다.

Zimmerman’s model of SRL is probably among the most popular.

• Boekaerts’ model emphasizes emotional aspects, 
• Corno’s the volitional aspect, and 
• Winne’s model underscores the cognitive aspects of SRL. 

무슨 모델이든 SRL은 다음과 같은 것을 함의한다.

Whichever the model, all assume that SRL implies 

• directing one’s learning by setting goals, 
• monitoring the learning process, and 
• using various cognitive and volitional strategies (Boekaerts & Corno, 2005; Pintrich, 2004).

이러한 첫 번째 정의는 두 개념의 유사성을 지적하는데, 비의존성과 agentic management 등이 그것이다. Lovens 등은 이렇게 말했다. '종합적으로 SDL과 SRL은 능동적 참여와 목표지향적 행동을 포함한다'. Pilling-Cormick과 Garrison 등에 의하면, SDL과 SRL은 모두 학습에 대한 책임과 통제를 의미한다. 

These first definitions point to the similarity of the two concepts, both aimed at describing the various dimensions of independent, agentic management of one’s learning efforts. Loyens et al. (2008, p. 417) note, “Overall, both SDL and SRL involve active engagement and goal-directed behavior.” According to Pilling- Cormick and Garrison (2007), SDL and SRL both address issues of responsibility and control in learning. 

3차원적 비교 

A Three-Dimensional Contrast

이전 문헌에서 다룬 바와 같이, "성인교육의 근간이 되는 SDL은 학교 외 환경에서 이뤄지는 학습의 역사의 개념이다. SRL은 반대로 학교 환경 내에서의 학습에 대해 연구해왔다". 둘 사이를 구분짓는 첫 번째 요소는 연구 전통이다.

As noted in previous reviews (Loyens et al., 2008, p. 418) “The adult education roots of SDL give this concept a history in learning outside school environments. . . . SRL, on the other hand, has been studied within school learning.” This first element accounts for two significant differentiating factors between both research traditions: 

• SRL is mostly concerned with school-based learning, hence mostly studied by educational psychologists, while 
• SDL, since its foundation, has been inspired by adults at grips with continuous formal or informal learning after their school years and hence has been mostly analyzed by adult education specialists. 

명백하게, SDL과 SRL은 학생의 통제에 대한 요소를 포함한다. 그러나 학습자가 가진 통제의 수준은, 특히 학습이 시작될 시점에서의 것이 SDL과 SRL이 다르다.

Clearly, both SDL and SRL carry an element of student control. However, the degree of control the learner has, specifically at the beginning of the learning process when the learning task is defined, differs in SDL and SRL. 

• SDL에서 학습과제는 항항 학습자로부터 시작된다. SDL학습자는 무엇을 학습할지를 정의할 줄 알아야 한다.
  In SDL, the learning task is always defined by the learner. A self-directed learner should be able to define what needs to be learned. . . . 
• SRL에서 학습과제는 교사가 정해줄 수도 있다. 이런 관점에서 SDL은 SRL을 포함한다.
  In SRL, the learning task can be generated by the teacher. . . . In this sense, SDL can encompass SRL, but the opposite does not hold. (p. 418) 

Loyens et al. (2008) state,

반대로, 이러한 구분은 SDL이 SRL을 포함함을 말한다. SDL하려면 SR할 수 있어야 한다.

Conversely, this distinction also implies that SDL requires SRL: one needs self- regulation to become a capable self-directed learner.

학교 시스템 내에 있는 학생들의 학습노력에 대한 연구를 다룬 교육심리연구에서 출발했다는 점에서 SRL으 주로 전략, 기술, 태도 등을 연구하며 더 넓은 목표는 학습자 자신에게 속하게 되지 않는다. 반대로 SDL연구는 성인교육 전문가에 의해서 수행되었고, Tough의 학습프로젝트라는 개념을 따르고 있다. 이는 학교 밖에서, 독립적인 학습자가 자기 결정적 교육 노력의 주된 의사결정자이다. 

Due to its origins in educational psychology’s studies of learning efforts of youth within the school system, SRL primarily investigates strategies, skills and attitudes favorable to an effective learning activity in constrained academic situations where the wider goals do not belong to the learners themselves. In contrast, investigations of SDL have been carried out by adult education specialists who, following the tradition of Tough’s notion of learning projects, have been mostly concerned with out-of-school, independent learners as the prime decision- makers of self-determined educational endeavors. 

학습프로젝트의 소유권이라는 측면에서, SDL에서 이것은 정의상 거의 학습자에게 있다. 반면 SRL에서는 외부에 의해서 통제될 수 있다. 반대로 말해서 agency가 둘 모두에서 핵심적 개념일지라도, SDL에서 이것은 보다 멀리 떨어지고 광범위한 목표를 의미하며, SRL에서는 가까운 목표에 제한된다. 이러한 SDL학습자는 학습의 궤적 전체를 조절하며, SRL학습자는 학습활동에 제한된 통제권을 가진다. 우리는 Lovens가 말한 것에 동의한다. SDL은 SRL을 의미할 수 있지만 그 반대는 아니다.

The difference lies in the ownership of the learning project, which rests, almost by definition, with the learner in SDL; while it could be controlled externally in SRL. In other words, while agency is at the core of both concepts, it applies to the larger distal goals in SDL but is restricted to proximal learning goals in SRL. The self-directed learner controls the learning trajectory as a whole, whereas the self-regulated learner’s control is restricted to the learning activity. We agree with Loyens et al. (2008) in stating that SDL can (and should) imply SRL, but the reverse is not true.

여기서 자기결정이란 학습자가 교육과 수련에 대한 옵션을 선택할 때 스스로 결정한다는 뜻이다.

Table 2 shows subcategory possibilities when crossing setting goals and achieving goals. Self-determination here means that the learners make their own decisions when choosing their options in education and training.

SRL은 방법론, 자원, 학습시간과 관련한 학생의 선택으로, 하나의 연속체로서 여겨진다. Winne이 말한 것과 같이 SRL은 학습에 있어 (인지적으로) 내재된 것이다. 비록 그 관여와 참여의 수준은 다를지라도 학습자는 메타인지적 모니터링 과정을 통해 학습에 대한 결정을 내리게 된다. 더 나아가서, 학습목표를 누가 설정했고, 학습상황이 어떻든간에 목표가 달성되기 위해서 그 목표는 보호받아야 하고 유지되어야 한다. 이러한 관점에서 SRL이 없는 상황은 사실상 거의 존재할 수 없으며, 이는 비록 학습상황이 거의 대부분 교사에 의해서 정의되고, 학습자의 선택이 매우 제한적인 상황에서도 그러하다. 이것이 우리가 SR의 부재 대신 낮은 SR이라고 언급한 이유이다.

Self-regulated learning is viewed as a continuum depending on the level of choices allowed to the student in terms of methodology, resources, or study time. As stated by Winne (1995), self-regulated learning is a cognitively inherent aspect of learning. Through the process of metacognitive monitoring the learner always makes decisions and controls his or her learning, albeit with a varying degree of engagement and success. Moreover, whatever the source of goals and the characteristics of the learning situation, goals often require protection and maintenance if they are to be met (Corno, 1993). In this sense, lack of self- regulated learning cannot really occur even though the learning situation is strongly defined by the teacher and curtails the learner’s choices. This is the reason why we used low level of self-regulation instead of lack of self-regulation in Table 2.

마지막으로 SDL과 SRL의 구분은 Rubicon 모델에 잘 맞는다. 이 모델에서는 Lewin의 목표달성을 위한 노력과 목표 설정에 대한 구분을 강조한다. 

Finally, the distinction between SDL and SRL nicely fits in the Rubicon model of action phases elaborated by Heckhausen (Heckhausen & Gollwitzer, 1986). This model capitalizes on Lewin’s distinction between goal striving and goal setting (Lewin, Dembo, Festinger, & Sears, 1944). 

• Goal striving is behavior directed toward existing goals, whereas 
• goal setting addresses the issue of what goals a person will choose. 

Heckhausen은 이 두 가지 문제를 하나의 이론적 모델로 합하여 deliberation부터 evaluation of action까지 네 단계를 구분하였다. 목표달성을 위한 노력은 '의지'이고, 목표 설정은 '동기'이다. SRL이론은 '의지'를 강조하고, SDL이론은 '숙고(deliberating)'단계를 강조한다.

Heckhausen has included these two problems into a single theoretical model that allows us to study the two steps in relation to each other and to introduce a temporal perspective by distinguishing four phases, from deliberation to evaluation of action. Goal striving is related to volition, goal setting to motivation. Being focused on the how of self-regulation, SRL theories enhance the volitional part of the learning process, whereas SDL theories focus on the deliberating phase of learning.

Target populations.

First, one should note that SDL is much more closely linked to adults than SRL. 

Conversely, SRL is more linked to academic achievement than SDL.

Theoretical framework. 

SRL연구는 인지심리학에 뿌리를 두고 있다.

Research on SRL is rooted in cognitive psychology. As stated by Winne (1996), research on metacognition and cognitive strategy “has built a broad platform for newer and increasingly more active work in SRL” (p. 327). Capitalizing on metacognitive theory, the SRL paradigm calls for expanding the study of learner activity by combining the investigation of cognitive, metacognitive and motivational processes in order to achieve a better understanding of autonomous learning (Cosnefroy, 2011).

SRL과 SDL모두 자율적 학습자가 무엇인가를 이해하고자 한다. 자율성은 동기 이론의 핵심이다. SDT는 자율과 통제된 자기조절을 구분한다. 

• 자율: 자기 지지적 통제 (self-endorsed regulation) 스스로의 행동을 인식는 것이 스스로에서(내부에서) 나오는 것.
• 통제된 자기조절: 한 사람의 행동은 자신 외부의 강제력에 의해서 이뤄지는 것.

SRL and SDL theories both attempt to understand what it means to be an autonomous learner. Autonomy is also at the core of a leading motivational theory. Self-determination theory (hereafter SDT) makes a distinction between autonomous and controlled self-regulation. The former is a self-endorsed regulation, the sense that one’s actions stem from oneself and are one’s own, whereas the latter means that the person’s behavior is regulated by coercive forces outside the self (Deci & Ryan, 2002).

두개의 평행우주?

Two Parallel Worlds?

SDL과 SRL 사이에는 연결이 약하다. 마찬가지로 SDT와도 연결이 약하다.

As shown above, there has been a significant increase in research on SDL and SRL from 2000 to 2010. The studies refer to one or the other but hardly ever to both concepts together, as if the research belonged to two parallel worlds without any connection. Likewise, there is a patent lack of connections with SDT, another theory that also focuses on autonomous self-regulation.

의사소통이 안 되는 이유

Conclusion: Three Combined Reasons Why Some Neighbors Don’t Communicate

It is hypothesized that three reasons account for the fact that such close conceptual neighbors don’t communicate – namely institutional differences, epistemological barriers, and scientific power issues.

• This first distinction accounts for the fact that researchers, practitioners, readers and potential users of the corresponding theories have seldom found common ground or circumstances to exchange ideas, concepts and experience relative to their (unbeknownst to them) common interest in various forms of learner autonomy.
• This second institutional divide, this time between university departments, reinforced mutual ignorance among faculty and students of both families. Respect for (or fear of) disciplinary frontiers may also have been reinforced by the classical phenomenon of paradigmatic closure, which Kuhn brought to light (Kuhn, 1962).
• Almost as a consequence of the preceding remarks, one could consider the lack of interaction between SRL and SDL as a key instance of scientific competition between rival academic groups.

SELF-REGULATED AND SELF-DIRECTED LEARNING: WHY DON’T SOME NEIGHBORS COMMUNICATE?

Laurent Cosnefroy and Philippe Carré

In connection with the ever-growing necessity of autonomous lifelong learning, psychological and educational research abounds with a plethora of self constructs. Among these, concepts that appear closely related seem to be used in complete ignorance of one another, thus appearing to operate within clearly segmented areas of empirical and academic subcultures. This paper examines two major constructs – self-regulated and self-directed learning – in order to (a) define them and establish their conceptual proximity and differences; (b) document the absence of links between them in the relevant literature(s); and (c) suggest three possible explanations for this mutual ignorance among close scientific kin. 

Keywords: self-directed learning, self-regulated learning, self-determination, selfefficacy, metacognition, autodidaxy, autonomy

미국 의과대학 입학생의 불확실성에 대한 내성 (Acad Med, 2014)

Ambiguity Tolerance of Students Matriculating to U.S. Medical Schools

Marie Caulfield, PhD, Kathryn Andolsek, MD, MPH, Douglas Grbic, PhD, and Lindsay Roskovensky

앞으로 다가올 삶의 우울한 특징은 우리의 과학과 예술 뿐 아니라 우리를 사람으로서 존재하게 하는 희망과 공포에 대한 것들에까지 존재하는 불확실성이다. 절대적 진실에는 도달할 수 없ㄷ으며, 우리는 부서진 일부를 찾는데 만족해야 한다. - 윌리암 오슬러

A distressing feature in the life of which you are about to enter … is the uncertainty which pertains not alone to our science and art, but also to the very hopes and fears which make us men. In seeking out the absolute Truth we aim at the unattainable, and must be content with finding broken portions. —Sir William Osler1

지난 수십년간 수많은 문헌에서 불확실성에 대한 내성이 의사의 중요한 역량이라고 해왔다.

A substantial body of literature over the past several decades suggests that tolerance for ambiguity is an important competency for physicians.2–4 As Geller4 recently pointed out, 

진료에서 개개인의 불확실성에 대한 낮은 내성은 검사 오더를 더 많이 내리게 만드는 결과를 가져오고, 근거중심 가이드라인을 따르지 않는 결과를 가져온다. 스크리닝 맘모그램의 recalling이 높아지고, 환자 비용이 높아지고, 유전자 검사의 음성 결과를 withhold하고, 오진에 따른 소송에 대한 공포가 높아지고, 죽음과 애도에 대해서 불편해하게 된다.

in medical practice, an individual’s low tolerance for ambiguity has been associated with … increased test- ordering tendencies and failure to comply with evidence-based guidelines,5 greater likelihood of recalling screening mammograms,6 increases in patient charges,7 withholding negative genetic test results,3 fear of malpractice litigation and defensive practice,8 and discomfort in the context of death and grief.9,10

불확실성에 대한 낮은 내성이 안좋은 결과를 가져오는 것과 함께, 높은 내성은 낮은 내성으로 인한 안좋은 결과를 줄임과 동시에 반대로 좋은 결과를 가져온다.

In addition to negative factors related to low tolerance for ambiguity, there also may be specific positive factors related to having a high tolerance for ambiguity, in addition to minimizing the negative factors

각 기관에서 강조하는 것.

• 의과대학 입학생 The Association of American Medical Colleges (AAMC) includes tolerance of and adaptation to stressful or changing environments as part of the Resiliency and Adaptability competency, which is one of the core competencies for entering medical students.17 
• 의과대학 졸업생 It also includes comfort with ambiguity in its published Core Entrustable Professional Activities,18 believed essential for graduated students entering residency programs. 
• 소아과 레지던트의 milestone The Accreditation Council for Graduate Medical Education (ACGME) considers tolerance for ambiguity as an essential “reporting milestone” under the Professionalism competency for pediatrics residents19;

Notably, no studies that we know of followed students longitudinally to examine stability of tolerance for ambiguity over time; a cross-sectional study that assessed students enrolled in medical school in Germany20 found below-average tolerance for ambiguity, with no differences across the students enrolled in the different years of school during that academic year.

2013년 처음으로 MSQ에 불확실성 내성(TFA) 스케일이 포함되었다.

In 2013, the modified tolerance for ambiguity (TFA) scale described above was, for the first time, included in the AAMC Matriculating Student Questionnaire (MSQ).25 Our study,

Participants and procedures

MSQ에는 다양한 설문문항이 포함된다. 2013년, 미국 내 140개 의과대학에 합격한 모든 학생에게 MSQ에 참여하도록 권고.

The MSQ contains a wide range of survey items, 

• including premedical experiences, 
• the medical school selection process, 
• personal characteristics and attitudes, and 
• specialty preferences and career plans. 

In 2013, individuals accepted for admission to any of the 140 U.S. medical schools that were accredited at that time by the Liaison Committee on Medical Education and that enrolled students in 2013 were invited by the AAMC to participate in the MSQ between June and mid- September.

Measures 

구성은 7개 문항

The seven-item TFA3 scale is a measure of one’s ability to cope with situations of uncertainty.

높은 점수가 높은 내성

Thus, higher scores are correlated with higher tolerance for ambiguity.

스트레스 인식 조사인 PSS도 MSQ에 포함됨. 이것은 10개 문항, 4점척도. 

The Perceived Stress Scale (PSS)26 is widely used for measuring the perception of stress. This 10-item scale measures the degree to which situations in one’s life are considered stressful. The PSS was included in the 2013 MSQ. PSS scores are calculated by summing across the 10 items, which are measured on a 0- to 4-point scale (never = 0, very often = 4).

'일차의료, 취약지에서 일할 의사가 있는가?' 문항도 포함됨

The survey also included the following item: “Do you plan to work primarily in an underserved area?” Response options were yes, no, and undecided.

Analytical approach 

신뢰도 분석(Cronbach alpha)

We first examined the internal consistency of the TFA and PSS scales using the Cronbach alpha test of reliability.27

남성과 여성의 차이가 줄어든 것은 밀레니엄 세대의 특징일 수 있다. (1980년~1999년 사이 출생) 이들 세대에서는 성 역할과 성 간 구분이 사라진다.

The narrowing of any difference between men and women may be due to the generational influences of the “Millennial generation.” Ninety- eight percent of the 13,867 survey participants who responded to the TFA items are in the Millennial age group of those born between 1980 and 1999. Some research suggests that gender distinctions and gender roles may be diminishing among those in the Millennial cohort.29

취약지에 근무하고자 하는 학생은 불확실성에 대한 내성이 높았다. 의료 접근성에 대한 격차가 커지고 SES, 인종, 민족, 지역에 따라 그 차이도 커지면서 의료취약지에 거주하는 사람들을 위한 의료인력에 대한 요구가 지속될 것이다. 따라서 의과대학은 TfA가 높은 학생을 입학절차에서 우선순위로 삼아야 한다.

Respondents who expressed an interest in working in an underserved area had higher tolerance for ambiguity than those who did not express such an interest. With disparities of health care access and outcomes recognized by socioeconomic status, race and ethnicity, and geography, there will continue to be a need for clinicians dedicated to patients living in underserved areas.30,31 Therefore, medical schools committed to addressing these problems may consider prioritizing personal characteristics such as tolerance for ambiguity in the admission process to enhance the likelihood that the future health care workforce will better address disparities in health care access.

Although the present study did not make predictions about which specialty preferences would be associated with different levels of tolerance for ambiguity, the exploratory analysis was consistent with some prior work in this area. For example, we found that the specialty preferences associated with the highest levels of tolerance for ambiguity included medical genetics, emergency medicine, and psychiatry;

스트레스에 대한 인식 역시 TFA와 연관되어 있었고, 스트레스를 많이 느낄수록 TFA가 낮았다.

Perceived stress was also associated with tolerance for ambiguity, as students with lower tolerance for ambiguity reported higher perceived stress levels.

의과대학생의 스트레스에 대한 대부분의 프로그램이 정신건강 서비스와 웰니스 프로그램이다. 그러나 이런 프로그램이 TFA 수준에 따라서 똑같이 효과적일지 혹은 이러한 프로그램이 TFA를 높일 수 있을지는 아직 모른다.

Most interventions to address medical student distress have focused on access to mental health services and wellness programs38; cognitive, behavioral, and mindfulness-based strategies39; and, more recently, curricular changes.40 It is

unknown whether these interventions are equally efficacious for students with different levels of tolerance for ambiguity or, relatedly, whether such interventions could increase an individual’s tolerance

25 Association of American Medical Colleges. 2013 MSQ All Schools Summary Report. ttps://www.aamc.org/data/msq/. Accessed July 9, 2014.

Ambiguity tolerance of students matriculating to U.S. medical schools.

의과대학 입학생의 성공에 필요한 핵심 인성역량 : 무엇이고, 어떻게 입학단계에서 평가할 수 있는가?(Acad Med, 2013)

Core Personal Competencies Important to Entering Students’ Success in Medical School: What Are They and How Could They Be Assessed Early in the Admission Process?

Thomas W. Koenig, MD, Samuel K. Parrish, MD, Carol A. Terregino, MD, Joy P. Williams, Dana M. Dunleavy, PhD, and Joseph M. Volsch, MPA

입학시에 의과대학 입학생이 지녀야 할 학업적 역량에 대해서는 일반적 합의가 있다.

There is general agreement in the medical education community about the academic competencies that medical students should demonstrate when they matriculate.

비록 의학교육계는 졸업시에 갖춰야 하는 인성역량에 대래서는 동의를 이뤘으나, 입학시에 어떠해야 하는가에 대해서는 합의가 없다.

Although the community has agreed on the personal competencies that medical students should demonstrate at graduation,1 it has not reached consensus on those that are important at entry or how to incorporate them into the admission process.

Albanese and colleagues2 estimated that more than 87 different personal qualities are assessed during the admission process. This lack of consensus among schools is surprising given that research has linked certain personal competencies to positive admission and medical school outcomes.

연구 결과를 살펴보면 어떤 인성 특징든 환자 성과, 환자들의 의사에 대한 평가에도 연관된다고 했다.

Researchers have related some of these personal characteristics and skills to improved patient care outcomes and to patients’ ratings of their physicians.5,6

관련된 연구 결과로는 다음과 같은 것이 있다.

• For example, good teamwork and collaboration are correlated with improved patient outcomes, patient satisfaction, and greater job satisfaction among physicians.7 
• Patients who report being treated with dignity by their physicians are more likely to adhere to treatment plans and to be satisfied with their care.8 
• Similarly, physicians who “adopt a warm, friendly, and reassuring manner” with their patients are more effective than those who keep consultations formal and do not offer reassurances.9 
• Recently, Hojat and colleagues10 found that patients of physicians with high levels of empathy have better health outcomes than patients of physicians with moderate and low levels of empathy. 
• Moreover, when physicians’ personal skills are lacking, negative professional outcomes are likely. 
• For instance, Papadakis and colleagues11 showed that unprofessional behavior in medical school (e.g., irresponsibility, lack of capacity for self-improvement) predicts later disciplinary action by state medical boards.

의과대학 입학에서 인성역량의 역할

The Role of Personal Competencies in Medical School Admissions

AAMC의 리더들과 다른 의학교육계 사람들은 지원자의 인성 특성을 더 강조해야 한다고 말했다.

Leaders of the Association of American Medical Colleges (AAMC)12 and others in the medical education community have called for more emphasis to be placed on applicants’ personal competencies in the admission process.

자료를 보면 면접까지 가기 전에 상당한 수의 지원자가 제외된다. 2011년, 한 지원자는 평균 14개의 의과대학에 지원했으나 평균적으로 2개 이하의 학교에서만 면접까지 갔다.

Data show that a significant part of admission screening takes place before interviews: In 2011, the average applicant submitted 14 applications but received less than 2 interview invitations.13

이 문제를 해결하기 위해서 가장 먼저 해야 할 것은 평가할 인성역량을 정하고, 의학교육계의 수요와 목적의 균형에 맞는 실무적, psychometric적 이슈를 해결하기 위한 도구에 합의해야 한다.

To meet this challenge, the medical education community must first agree on a universal set of personal competencies to measure as well as a set of tools that balances the needs and goals of the admission community with practical (e.g., cost, accessibility) and psychometric issues.

Defining Core Personal Competencies for Entering Medical Students

Although there have been attempts to systematically define the personal competencies that medical school matriculants should demonstrate on entry (e.g., the AAMC explored this in the 1970s and 1990s),16 there has been little effort to build consensus about these competencies in the wider medicaleducation community. Therefore, the AAMC undertook a rigorous, multi- year process to research and identify core personal competencies for students entering medical school in the 21st century. This process (Table 1) 

16 Etienne PMJ, Julian ER. Assessing the personal characteristics of premedical students. In: Camara WKE, ed. Choosing Students: Higher Education Admissions Tools for the 21st Century. Mahwah, NJ: Lawrence Erlbaum Associates; 2005.

의과대학 성공에 중요한 인적 특성

Identifying personal characteristics important to success in medical school

MR5 Committee는 두 개의 설문 진행

The MR5 Committee began the process by conducting two surveys

• In 2008, U.S. and Canadian admission officers were asked to describe their school’s admission process and to rate the importance of 41 personal characteristics to success in medical school.
• In 2009, U.S. and Canadian academic affairs officers were asked to rate the importance of 72 characteristics to success in medical school. Data from these two surveys17,18

핵심 인성역량 개발

Developing the set of core personal competencies

평균적으로 매우-극도로 중요하다고 평가하였으나, 입학과정에서 관련되어 제공되는 정보의 질에는 만족하지 못함

As shown in Table 2, on average, all of the draft personal competencies were rated by admission officials as “very important” to “extremely important.” Respondents were not, however, satisfied with the quality of information available about these competencies during the admission process.

피드백 수집

Collecting feedback on the core personal competencies

The ILWG’s recommendation served as the foundation for the AAMC Admissions Initiative. One of that group’s first projects was to review the ILWG’s draft definitions of the recommended core personal competencies.

9개의 핵심인성역량 승인

Approving the nine core personal competencies for entering medical students

2013년 2월 AAMC COA는 최종 9개 리스트를 만들었다. 

In February 2013, the AAMC’s COA endorsed the final list of nine core personal competencies for entering medical students (defined in Table 4): 

• ethical responsibility to self and others; 
• reliability and dependability; 
• service orientation; 
• social skills; 
• capacity for improvement; 
• resilience and adaptability; 
• cultural competence; 
• oral communication; and 
• teamwork.

평가도구 검색

Exploring Tools to Assess the Core Personal Competencies Early in the Admission Process

비록 ILWG 설문이 인성역량을 평가하는 도구도 제안하긴 했지만, 그것의 활용과 가치에 대해서는 아직 답해야 할 질문이 많다.

Although the ILWG survey suggested a desire among admission officers for tools that assess applicants’ personal competencies early in the admission process, there are many unanswered questions about the use and value of such measures in medical school admissions.22

50개 이상의 논문, 6개의 미발표된 보고서 등등을 보았음.

We identified more than 50 seminal articles (including several meta-analyses) and six nonpublished technical reports about tools currently used to measure personal competencies in higher education and employment settings. We made subjective, holistic judgments about tools’ potential to provide information on applicants’ core personal competencies for use in the pre-interview screening stage of the admission process. 

여섯 개의 도구를 여덟 개의 준거로 평가하였다.

We judged six types of tools according to the following eight criteria: 

• validity, 
• reliability, 
• group differences, 
• susceptibility to faking and coaching, 
• applicant reactions, 
• user reactions, 
• cost/resource utilization, and 
• scalability for use in pre-interview screening (Appendix 1).

SJT수행에 약간의 인종/민족간 차이가 있을 수 있다. 그러나 법과대학 결과를 보면 AA나 Latino의 입학을 더 높여준다.

There is some evidence suggesting that there may be small racial/ethnic group differences in performance on SJTs that emphasize decision making.31 However, research conducted by the College Board and the Law School Admission Council indicates that including these tests in the admission process may increase the percentage of African American and Latino matriculants compared with using academic data alone, and that performance on SJTs is the best predictor of “lawyering effectiveness.”32,33

SJT는 개발에 비용이 많이 들며, 시나리오 개발에 기술전문가가 필요하다. 그러나 면접 전 스크리닝에 scalable하며 대규모의 지원자에게 시행할 수 있다. 결과 자료도 활용하기 용이하다.

SJTs are somewhat expensive to develop because of the technical expertise needed to create and score scenarios. However, they are scalable for use in pre-interview screening because they can be administered to a large number of applicants before the interview. Further, when SJTs are scored, data are presented in a format that is easy to consume.

표준화 수행 평가(SEP)

Standardized evaluations of performance

평가자는 그래픽, 상호비교, 행동-관련-평가스케일을 활용하여 지원자를 특정 역량에 따라 평가한다.

In standardized evaluations of performance (SEPs), raters use a graphic, comparative, or behaviorally anchored rating scale to evaluate applicants on a set of competencies.

대부분의 의과대학 입학절차에서 비표준화 추천서를 사용하지만, 비학업적 변인에 대해서는 평가자간 신뢰도가 낮고, 예측 타당도도 낮고, comparative data도 부족하다. 다른 전문직 교육과정에서는 SEP을 사용해왔으며 ETS에서는 PPI를 도입했다. 

Although most medical school admission processes use nonstandardized letters of recommendation—which have poor interrater reliability for nonacademic variables,34 have poor predictive validity, and lack comparative data—other graduate and professional program (e.g., veterinary medicine, optometry, physical therapy) admission processes use SEPs. In 2009, the Educational Testing Service introduced the Personal Potential Index,35 an SEP for use in graduate admissions, but there is no published literature to date on its psychometric properties.

의과대학 지원자의 수행능력을 보면 SEP 점수와 작지만 유의미한 정의 상관관계를 확인할 수 있다. 입학담당자는 SEP에 긍정적인 태도를 가질 가능성이 높은데, 왜냐하면 평가자들이 지원자의 인성역량을 묘사할 구체적인 행동 예시를 포함시켜야 하기 때문이다.

Research on the Medical Student Performance Evaluation shows small but significant observed positive correlations between standardized evaluations and performance on comprehensive clinical performance exams.36 Admission officers are likely to have positive attitudes about SEPs because raters must include specific examples of behaviors illustrating applicants’ personal competencies.37

점수를 잘 주는 평가자가 있을 수 있고 평가에 variance가 있을 수 있다.

There is potential for rater leniency and consequent lack of variance in ratings, though.

신뢰도는 이러한 성취기록이 감독관이 있는 상황에서 수집되고, 다수의 평가자가 평가하여 확보할 수 있다. 타당도 자료는 수집 불가능하다. 지원자와 의과대학은 미적지근할 수 있는데 일이 늘어나기 때문이다. 점수를 부여하지 않은 성취기록에 대해서는 거의 문헌자료가 없으나 개발이 어렵지 않고 다수의 지원자에게 적용가능하다.

Reliability is best when accomplishment records are collected in proctored settings and are scored by multiple raters.39 Validity data are not available with respect to their use in admissions. Applicants and users may have lukewarm reactions to them because of the added workload. There is little published research on unscored accomplishment records, but they are inexpensive to develop and can be administered to large numbers of applicants.

면접

Local interviews

인터뷰 종류는 비구조화에서 구조화까지 다양하나 대부분 반구조화 면접을 사용한다.

Interview types range from unstructured to structured, but most medical school interviews are semistructured.

면접은 한계가 많은데, 우선 비구조화 면접의 신뢰도가 낮으며, 지원자의 지원서 자료를 같이 면접관에게 제공하는 평가에 오류가 생길 가능성이 높다. 또한 평가자 오류가 있을 수 있고, 지원자보다 평가자에 따라 점수가 달라진다.

Local interviews have a number of limitations, however. Reliability for unstructured interviews is poor, and the practice of providing interviewers with access to applicants’ application data introduces bias.42,43 In addition, local interviews are subject to rater error, and ratings may have more to do with the interviewer than the interviewee.43 

구조화된 면접은 다음과 같은 것이 있다.

structured interviews conducted at the University of Iowa Carver College of Medicine,47 and “behavioral event interviews” used by the Scholarly Excellence, Leadership Experiences, Collaborative Training program at the Morsani College of Medicine48

우리의 권고는 SJT, SEP, 성취기록이다.

After reviewing the literature and evaluating potential tools on the eight criteria, we suggested that the AAMC further investigate three tools for possible use in assessing applicants’ core personal competencies during the admission process: SJTs, SEPs, and accomplishment records. We recommended these tools because each of them

그 이유는 아래와 같다.

• provides data about personal competencies in a format that is easy to use and would be available in time for pre-interview screening, 

• allows for multiple sources of assessment, 

• has acceptable validity and is likely to provide predictive value beyond UGPAs and MCAT scores in predicting nonacademic outcomes, 

• demonstrates less potential risk of coaching and faking effects compared with other tools, 

• is likely to be accepted by applicants and admission officers, and 

• avoids exorbitant costs that would likely be passed on to applicants.

어떤 도구도 모든 상황에 완벽하지 않아서 다양한 도구를 사용할 것을 권고한다. SJT SEP 성취기록은 모두 toolbox로서 함께 사용되어야 한다.

No tool is perfect for all situations, so we recommend that multiple tools be employed to assess personal competencies to enable admission officers to evaluate the information collected (just as they currently consider both UGPAs and MCAT scores in context). SJTs, SEPs, and accomplishment records should be used together—as part of an “admissions toolbox”—along with data on applicants’ academic competencies, in deciding which applicants to interview.

SJT에 대한 연구가 더 필요하다. 

Future research on the use of SJTs in medical school admissions should explore different formats for 

• presenting scenarios (e.g., actors, avatars), 
• alternative response formats (e.g., rank order, narrative responses), 
• validity, and 
• the impact of coaching/faking on validity and user acceptance.

2 Albanese MA, Snow MH, Skochelak SE, Huggett KN, Farrell PM. Assessing personal qualities in medical school admissions. Acad Med. 2003;78:313–321.

22 Bardes CL, Best PC, Kremer SJ, Dienstag JL. Perspective: Medical school admissions and noncognitive testing: Some open questions. Acad Med. 2009;84:1360–1363. Acad Med. 2009;84:1360–1363. 

SJT 23 Dore KL, Reiter HI, Eva KW, et al. Extending the interview to all medical school candidates—Computer-Based Multiple Sample Evaluation of Noncognitive Skills (CMSENS). Acad Med. 2009;84(10 suppl):S9–S12. 

SJT 24 Lievens F, Sackett PR, Buyse T. The effects of response instructions on situational judgment test performance and validity in a high-stakes context. J Appl Psychol. 2009;94:1095–1101. 

SJT 25 Lievens F, Sackett PR. Situational judgment tests in high-stakes settings: Issues and strategies with generating alternate forms. J Appl Psychol. 2007;92:1043–1055. 

SJT 26 Lievens F, Sackett PR. The validity of interpersonal skills assessment via situational judgment tests for predicting academic success and job performance. J Appl Psychol. 2012;97:460–468. 

SJT 27 Ziv A, Rubin O, Moshinsky A, et al. MOR: A simulation-based assessment centre for evaluating the personal and interpersonal qualities of medical school candidates. Med Educ. 2008;42:991–998.

SEP 35 ETS. ETS Personal Potential Index. http:// www.ets.org/ppi. Accessed January 25, 2013.

Structured Interview 48 Carney A. Building a better doctor. USF Magazine. 2011:53(3). http://www.magazine. usf.edu/2011-fall/building-a-better-doctor. aspx. Accessed January 14, 2013.

Core personal competencies important to entering students' success in medical school: what are they and how could they be assessed early in the admission process?

지난 25년간의 의과대학 입학과 관련된 연구와 실제(Teach Learn Med, 2013)

A Perspective on Medical School Admission Research and Practice Over the Last 25 Years

Clarence D. Kreiter and Rick D. Axelson

Department of Family Medicine, University of Iowa Carver College of Medicine, Iowa City, Iowa, USA

다양한 관점에도 불구하고 입학 프로그램은 상당히 보수적인 편이다. 실제로 지난 25년간 북미 의과대학의 학생선발 과정을 보면 거의 변한게 없다.

Despite a wide diversity of viewpoints, admission programs tend to be quiteconservative and to perpetuate the professional status quo. Infact, a comparison between current admission practices at North American medical schools and those used 25 years ago suggest that procedures have changed very little.1–4

한 가지 가능한 설명은 개념적 장벽, 그리고 기관 차원의 장벽이다.

A more likely explanation is that conceptual and organizational barriers have slowed evidence-based progress.

연구 결과 활용의 장애요인

BARRIERS TO THE USE OF RESEARCH FINDINGS

우리가 보는 관점에서, 발전을 저해하는 가장 중요한 요소는 공통의 의제와 개념 토대의 부족이다.

In our view, what has most slowed progress has been the lack of a shared agenda and conceptual foundation for guiding scholarship on admission issues.

발전을 저해하는 첫 번째 개념적 문제는 의과대학이 지원자에서 어떤 부분을 평가하고자 하는 것에 대한 모호함이다. 여러 의과대학에서 평가하는 인적 특성의 다양성은 의과대학 지원자에게 바라는 바람직한 특성에 대한 합의가 적음을 뜻한다.

The primary conceptual problem hindering admission pro- cess refinement has been ambiguity regarding what medical schools are looking for in candidates. The wide range of per- sonal qualities that are purportedly being assessed by different colleges indicate that there is little agreement regarding the desired attributes.7

AAMC의 COA는 ILWG의 결과물에 네 개의 추론과 두 개의 핵심 과학 역량을 더했다.

The AAMC’s Committee on Admissions, building upon the work of the Innovation Lab Working Group, specified four reasoning and two science core competencies 

이 역량 목록에 대한 동의를 만드는 것이 이 문제를 해결하고 지원자에게 요구되는 바람직한 특성과 관련된 여러 이슈들을 해결하는데 도움이 될 것이다.

Agreement on this list of competencies will likely be an important step toward resolution of this matter and other issues conflated with the debate over desired candidate qualities.

보다 덜한 장애요인 중 하나는 학생선발의 목적이 복잡하다는 것에 있다. 다양한 목적들이 있으며, 이는 서로 상충하기도 하고, 각각은 다시 다양한 하부 이슈로 구성되어 있어서 학생 선발에 관한 의사결정 환경은 다면적인 특성을 지닌다. 이 복잡성은 과연 validity에 대한 근거가 선발 절차에 적용되기는 하는가에 대한 의구심을 낳는다. 비록 validity theory는 한 프로그램이 어떤 목적을 가지고 있느냐에 대해서는 중립적이지만, 변화에 대한 보수적인 관점과 새로운 근거기반 방법론을 지지하는 사람간의 관점 차이는 그 사람이 psychometric validity가 특정 목적이나 목표를 향해서 편향되어있는지 여부에 어떻게 생각하느냐에 달려있다.

A less recognized obstacle to evidence-based progress relates to the complexity of admission goals. The broad and often competing concerns for social justice, educational quality, and healthcare outcomes each contain numerous subsidiary issues that ultimately create a multifaceted and complex decision environment.This complexity has led some to question whether validity evidence even applies to selection procedures. Although validity theory is neutral regarding what goals are set for a program,often the difference between a conservative viewpoint toward change and one that advocates new evidence-based methods hinges upon whether one believes that psychometric validity is inherently biased in favor of a particular goal or objective. 

근거기반 방법론을 활용하는데 관련된 또 하나의 장애는 증가하는 정치적, 법적 압박이다. 비록 학생선발 절차가 그러한 압력에 반응해야 하는 것은 맞지만, 우리는 과학적 타당도 근거가 법적/정치적 영역에서도 공정성과 효율성을 정의하는 것의 핵심이 되어야 한다고 생각한다.

A related obstacle for utilizing evidence-based methods stems from the increasingly strong political and legal pressures placed on medical schools. Although it is clear that the admissions process must respond to such pressures, we believe that scientific validity evidence should be instrumental in defining fairness and efficiency in both the legal and political arenas.

입학절차는 미국 의학교육에 큰 영향을 미쳐왔다. 효과적인 교육적 개입은 고작해야 효과크기 0.20혹은 그 이하 정도의 이득에 그치나, 근거중심 선발의 효과는 훨씬 더 강하다. 실제로 잘 설계된 선발 절차는 수행능력을 1 SD 이상 향상시킬 수 있다.

Admission procedures have had a profound impact on North American medical education. Although effective educational interventions typically produce only small gains in learning, usually with effect sizes of .20 or less, evidence-based selec- tion is comparatively far more powerful. In fact, when well de- signed, selection procedures in medical education can achieve performance gains easily exceeding 1 standard deviation.14–16

1. 인터뷰와 관련 기술들

1. The Interview and Related Techniques

어떤 도구의 타당도도 그 신뢰도의 SQRT값을 초과할 수 없기 때문에, 입학 전 면접 성적의 재현가능성은 타당도의 필요조건이다.

Because the maximum validity displayed by any measure cannot exceed the square root of its reliability, establishing the reproducibility of the preadmission interview score is a nec- essary precondition for validity.

완벽한 시험-재시험 방식의 신뢰도가 면접의 유용성을 결정하는데 가장 관련이 높기 때문에, 다면화된 일반화가능도 분석을 통해 도출한 G 계수가 - 평가자간, 평가자내 일관성 지표보다 - 가장 이론적으로 면접의 타당성을 잘 보여준다.

Because a comprehensive test–retest type of reliability is the most relevant for determining the utility of the interview, a G coefficient from a multifaceted generaliz- ability analysis, rather than an interrater or internal consistency index, has the most theoretical relevance for establishing the validity of the interview.

연구 결과를 살펴보면, 전통적인 방식의 입학면접 점수는 전반적으로 재현가능성이 매우 낮으며, 이 낮은 신뢰도로부터의 타당도 역시 면접이 중요한 성과들을 예측하는데 효과가 없음을 보여주고 있다. 이러한 결과는 입학면접을 매우 강조하는 대부분의 북미 의과대학에 시사하는 바가 크다. 명백하게, 전통적인 면접은 선발에서 중요한 요소가 되어서는 안된다. 그리고 면접 점수를 최종 결정에 활용하는 것은 공정하고 타당한 평가가 이루어질 것이라는 지원자의 기대에 반하는 것이다.

Research suggests that the overall re- producibility of the traditional preadmission interview score is very low, and the validity implication of this lowreliability have been confirmed by studies demonstrating that the interviewis in- effective in predicting important outcomes.18–22 These findings have significance for the majority of North American medical schools as they continue to maintaining a strong emphasis on the preadmission interview.1,2 Clearly, the traditional interview should not be an influential component in selection, and the use of an interview score to make the final decision may violate an applicant’s expectation of fair and valid assessment practice.9

The MMI has as its most important innovation, the use of objectivelystructuredclinical examination–style mea- surement techniques.23 This well-examined assessment method, using multiple independently rated samples of behavior, has consistently produced summary measures displaying accept- able reliability and promising validity evidence.24–28 Although the MMI has not been widely adopted, perhaps due to the com- plexity of the measurement process, it does demonstrate the fea- sibility of generating a reliable nonacademic assessment from an interview-like procedure. Although it is clear that multi- ple independent measures of performance are needed, there are competing concepts regarding which behaviors should be ob- served and rated.19,26 

2. 입학 시험

2. Admission Tests

가장 높은 예측력에도 불구하고 입학시험을 활용하는 것의 타당도에 대해서는 의견이 갈린다. 예컨대 MCAT이 어떤 임상기술이나 의과대학 후반/전공의/진료의 성취 결과를 예측하는데 비효과적이라는 결과로부터 어떤 사람들은 MCAT이 선발에서 제한적으로만 활용되어야 한다고 주장한다.

Despite generating the highest predictive coefficients, there have been conflicting views regarding the validity of using an aptitude/achievement test for selecting applicants to study medicine. For example, because the MCAT has been reported to be ineffective in predicting certain clinical skill and achieve- ment outcome measures fromthe later years of medical school, residency, and practice, some have maintained that the MCAT is of limited use in selection.31–35

메타분석을 해보면, 타당도에 대한 일반화 연구로부터 MCAT의 예측력이 비교적 의과대학 전 학년에 걸쳐서 일관되게 나타나며 MCAT이 시험점수로 나타나는 학업성취 뿐 아니라 임상기술 예측도 잘 하는 것을 보여준다.

Using meta-analytic techniques, validity generalization research has convincingly demonstrated that the predictive power of the MCAT remains relatively consistent across the medical school years and beyond and that the MCAT tends to predict clinical skills almost as well as written test-based academic achievement outcomes.15

입학시험은, 그 이름을 뭐라고 부르든, 일반적인 지능 및 추론 능력과 매우 높은 상관이 있다. 이는 입학시험을 바탕으로 한 선발은 지능을 바탕으로 한 선발이라는 의미이기도 하다.

Admission tests, whether labeled as aptitude or achievementassessments, are highly correlated with general intelligence andthe ability to reason.38,39 This implies that selection based onadmission testing also selects on general intelligence. 

다른 학생선발 맥락과 비교해보면, 의학교육에서 선발을 하는 사람들은 대른 분야에 비해서 고도로 동기부여가 되어있고 똑똑한 학생 중에서 산발하는 것이다. 이런 이유로 informed selection 방법은 겨우 의과대학 지원요건/면허취득요건을 충족한 지원자를 찾는 것보다 훨씬 더 능력 있는 지원자를 선발하는 것이다.

Compared to other selection contexts, medical education ad- mission professionals are in the enviable position of being able to select from a large pool of highly motivated and intelligent applicants. For this reason, informed selection methods are ca- pable of achieving far more than identifying applicants who will merely pass the requirements of medical school and the associated licensure and certification examinations.42

Section 4에서 논의할 것과 마찬가지로, 이 결론의 함의는 다양한 입학 프로그램의 목적을 달성하고자 할 때, 가장 타당한 모델은 MCAT 평균점수를 최대화하되, 다른 유형의 목표에 의해서 제한되도록 하는 것이다.

As we discuss in Section 4, the practical implication of this conclusion is that when attempting to achieve diverse admission programobjectives, the most valid models are those that maximize the average MCAT within the constraints imposed by other class composition goals.43,44

MCAT과 관련된 중요한 이슈 중 하나는 uGPA와 높은 상관이 있다는 점이다. 두 척도간에는 다중공선성이 높아 MCAT이 의과대학 성적이나 USMLE 점수를 예측하는데 약간정도만 기여하게 된다. 따라서 MCAT을 배제하고 uGPA만 사용하는 것이 타당해 보일 수 있으나, MCAT을 유지해야 하는 이유가 있다. 하나는 대학 성적의 의미는 대학이 어디인지 전공이 무엇인지 따라서 매우 다르다는 것이다. 또한 이러한 이유로 uGPA만 활용하는 것은 불공정하고 교육 절차를 훼손시킬 수 있다. MCAT은 uGPA를 여러 대학간 동질화시키는 효과적인 수단이다.

An additional and important interpretive issue concerning MCAT research relates to the fact that admission test scores correlate highly with undergraduate grade point average (uGPA). Multicollinearity between the two measures results in the MCAT contributing only modestly to the incremental vari- ance explained in medical school grades and USMLE scores.14 Althoughit might therefore seemreasonable tosimplyuse uGPAwithout MCAT, there are compelling reasons to retain MCATin the selection process. One of the primary shortcomings ofcollege grades relates to the fact that the meaning of uGPAvaries dramatically across undergraduate institutions and ma-jors.45 The variability in standards across institutions suggeststhat it is unfair and likely damaging to the educational process,to use uGPA in isolation. Because MCAT is an effective meansof equating uGPA across institutions, it also serves a vital rolein maintaining the integrity of our educational metrics.46 

3. 개인 역량에 대한 다른 척도들

3. Other Measures of Personal Competencies

Although their average predictive validity appears to be quite low, Tett and Christiansen50 argued that when well-constructed personality tests are used under the proper conditions, they can achieve useful levels of predictive validity. For our purposes, the issue then becomes whether the proper test(s) and conditions can be developed for selecting medical school applicants with sufficient predictive validity. 

There is considerable skepticism regarding whether theseconditions can be attained in medical student selection pro-cesses. As Bardes et al.52 noted, although there is some ev-idence of links between noncognitive measures and medicalstudent performance, these studies were based on medical stu-dents rather than applicants. Given the high stakes nature of theselection process, there is strong incentive for applicants to givethe answers desired by an admissions committee rather than an-swering questions candidly

자기소개서는 세 번째 방법

Autobiographical essays are a third method for collective information about nonacademic attributes. 

의과대학이 이 정보를 수집하고 점수를 매기는 방법은 매우 다양하며 멕마스터대학에서의 연구에 따르면 평가자간 신뢰도가 낮아서 성과 척도와 낮은 상관관계만을 보여준다. 

There appears to be much variation in how medical schools collect and score this information. Re- search conducted at McMaster University suggests that scores on the essays have little correlation with outcome measures, at least in part, because of their low interrater reliability.22 Subse- quent research found that the reliability and predictive potential for these scores was improved by administering the essays in an onsite, proctored, time-controlled environment and by rating the resulting essays using a horizontal scoring method.53

따라서 위의 세 가지 중에서는 현재로는 지침에 따라 작성하는 표준화된 추천서가 personal competency를 평가하는 가장 좋은 방법으로보인다.

Thus at present, standardized letters of recommendation guided by instructions such as those developed by the AAMC’s Admission Initiative appear to be the most promising of these three methods for gathering reliable and valid information about candidates’ personal competencies through admission processes.

SJT와 Sternberg's successful intelligence test도 있다.

Situational judgment tests (mentioned earlier) and Sternberg’s successful intelligence test54 are two examples of ability-based tests that might capture additional information about applicants’ personal competencies. Successful intelli- gence includes creative and practical skills that enable individuals to envision, evaluate, and implement practical solutions to problems. Using a sample of 793 college students, Sternberg54 showed that such measures substantially improved the predic- tion of students’ college GPA.

4. 합격자 결정 과정

4. The Decision Process

안타깝게도, 지난 25년간 성과 척도를 개발하는데 거의 자원이 투입되지 않았다. 많은 연구들이 성공적인 학생 똔느 의사를 만드는데는 많은 요소가 필요함을 인정하지만, 정확상과 편의성을 이유로 성적/면허시험점수/증명서 등에 안주하고 있다.

Regrettably, over the last 25 years, there have been fewresourcesallocated toward the development of outcome measures. Moststudies acknowledge that there are many elements that define a successful student or physician, but for reasons of measurement precision and convenience, settle for grades, licensure scores, and/or successful certification.

사용가능한 다양한, 하지만 불완전한 지표들을 합하여 척도를 만드는 것이 지금까지 간과되어 온 방법이다. 통계적인 insight에 따르면, 척도가 다양하더라도 우리가 성공적인 의사라고 정의한 그 방향을 모두 일관되게 향하고 있다면 그것들을 합함으로써 신뢰도와 타당도 높은 결과를 얻을 수있다.

One overlooked method for building an index that could pos- sibly reflect physician success might be found in a composite measure constructed from a large set of available but imperfect indicators. Statistical insights suggest that if the components of a composite measure all vary in the same direction as what we are trying to define/predict (a successful physician), a reli- able and valid composite is likely to evolve.

어떤 사람은 어떻게 이렇게 다양한 요소들을 - 각각이 기여하는 정도가 어느 정도인지도 모르고서 - 합할 수 있느냐고 무렁볼 수 있는데, 통계 연구를 살펴보면, 비록 어떤 요소들이 더 중요하고 더 신뢰도가 높을 수있지만, 표준화된 점수를 합하는 것 만으로도 가중치가 적용된 점수와 거의 완벽하게 상관관계를 가진다.

One might wonder howweights for such diverse components could possibly be generated when we have so little knowledge about each indicator’s relative contribution in defining the con- struct. Fortunately, statistical research demonstrates that this problem is easily solved. Although it is reasonable to regard some of these component indicators as more important and re- liable than others, statistical evidence clearly indicates that a sum of standardized scores (simple unit weighting) will gener- ate a composite almost perfectly correlated with any optimally weighted composite we might derive with more complete information.60

19. Axelson RD, Kreiter CD. Rater and occasion impacts on expected pread- mission interview reliability. Medical Education 2009;43:1198–202.

26. Ziv A, Rubin O, Moshinsky A, Gafni N, Kotler M, Dagan Y, et al. MOR: A simulation-based assessment centre for evaluating the personal and interpersonal qualities of medical school candidates. Medical Education 2008;42:991–8.

43. Kreiter CD. The use of constrained optimization to facilitate admission decisions. Academic Medicine 2002;77:148–51. 44. Kreiter CD, Stansfield B, James PA, Solow C. A model for diversity in admissions: Areviewof issues and methods and an experimental approach. Teaching and Learning in Medicine 2003;15:116–22.

48. Siu E, Reiter H. Overview: What’s worked and what hasn’t as a guide to- wards predictive admissions tool development. Advances inHealthSciences Education 2009;14:759–75.

49. Association of American Medical Colleges. Guideline for writing letter of evaluation for a medical school applicant. 2011. Available at: https://www. aamc.org/initiatives/admissionsinitiative/letters./ Accessed July 15, 2013.

A perspective on medical school admission research and practice over the last 25 years.

학부의학교육과 의사 프로페셔널리즘의 토대(JAMA, 2015)

Undergraduate Medical Education and the Foundation of Physician Professionalism

Darrell G. Kirch,MD Association of American Medical Colleges,Washington, DC.

Maryellen E. Gusic, MD Association of American Medical Colleges,Washington, DC.

CoriAst,MHSA Association of American Medical Colleges,Washington, DC.

프로페셔널리즘은 이렇게 정의된다.

Professionalism is the demonstrated “commitment to carrying out professional responsibilities and an adherence to ethical principles”1 

여러 전문직 조직에서 어떻게 의사들의 프로페셔널리즘을 유지할 것인가에 대한 논쟁이 있지만, 학부의학교육에서는 공유거버넌스 모델(shared governance model)이 이 중요한 역량 개발의 프레임워크를 제공한다.

Although there is current controversy regarding how diverse professional organizations should ensure professionalism among practicing physicians, during undergraduate medical education a shared governance model, as described below, provides the framework for developing and accessing this critical competency.

프로페셔널리즘의 토대는 의과대학 이전에 시작된다.

The Foundation of Professionalism Begins Before Medical School

Aspiring physicians, through many years of personal ex- periences prior tomedical school, establishthe “prepro- fessional” foundation for competence in professional- ism, making it important to assess preprofessional attributes in medical school admissions.

전-프로페셔널리즘 역량에 대한 평가는 의과대학에서 "전인 평가"의 핵심이다.

The evaluation of preprofessional competencies is central to the “holistic review” of medical school applicants.

의과대학 학생선발 절차의 중심에는 MCAT이 있는데, 이 MCAT은 최근 21세기 의사에게 필요한 더 광범위한 포트폴리오를 요구하는 방향으로 수정되었다.

Central to the admissions process, the Medical College Admissions Test (MCAT) has recently been revised to emphasize the broader portfolio of skills required by physicians in the 21st century. 

개정된 MCAT은 다른 몇 가지 선발절차의 변화와 동반되고 있는데, 그 중 하나는 추천서 작성에 대한 가이드라인을 만든 것이다. 또한 표준화된 지원서 양식을 통해 학사 학업내용 뿐 아니라 관련된 개인 경험을 기술하도록 하였다.

The revised MCAT has been coupled with other changes in the admissions process, including the creation of guidelines for letters of recommenda- tion to ensure inclusion of information about the core competencies for entering medical students and, in the standardized application form, asking applicants to document relevant personal experiences in addition to their coursework.

도입 초기이지만 MMI는 의과대학 수행능력을 예측하는 것으로 보인다.

In early stages of implemen- tation, MMIs appear predictive of future performance in medical school.4

아직 미국 내에서는 검토단계이지만 SJT는 벨기에 의대생 선발에서 1997년부터 사용되어왔다.

Although still under assessment in the United States, an SJT has been used by Belgium for medical school admission since 1997.2

Increasingly, it is recognized that professionalism is not cultivated solely by role-modeling in clinical settings but rather that pro-fessionalism must be taught early, longitudinally, and deliberately using both targeted instruction and experiential learning. The LCME accreditation standards formalize the institutional responsibility by requiring that medical schools maintain a learning environment that cultivates the development of professionalism among learners. 

중요한 점은, 한 학생이 전문직으로 성장하는 것에 대한 책임은 행정, 교수, 학생이 모두 공유하는 것이다.

Importantly, this responsibility for students’ professional development is shared with administrators, faculty, and students serving on various administrative committees.

To support these assessments, more than half of medical schools in the United States and Canada rely on 

“defined, written standards of non-cognitive behavior, [including] 

• honesty; 
• professional behavior; 
• dedication to learning; 
• professional appearance; 
• respect for law and others; 
• [and adherence to standards related to] confidentiality; and 
• [lack of issues related to] substance abuse,” 

in addition to the academic standards for promotion established by each school.6 

프로페셔널리즘 평가는 생화학 지식 평가보다는 덜 정확할지 모르나, 다양한 도구들이 있다.

Although assessing competence in professionalism may be less precise than assessing competence in the knowledge of biochemistry, today there are tools to assess professionalism in students, including 

• patient evaluations, 
• self and peer assessments, 
• behavioral observation, 
• psychological testing, and 
• even structured examinations.6

"한 아이를 키우는데는 한 마을이 필요하다"라는 말이 있듯, 이는 의사를 양성하는 것에도 마찬가지이다. 

The dictumthat “it takes a village to raise a child” also appears to be true of educating a physician. Although the ultimate responsibility for professionalism rests with the physician aspirant, multiple parties are involved in shaping the preprofessional attributes of aspiring physicians, as well as those in the undergraduate process of training, including 

committees for admissions, curriculum, and progression that engage administrators, faculty, and students in the oversight, development, and assessment of professionalism. Affiliated organizations, including the LCME and AAMC, play a significant role in setting standards and providing tools related to teaching and assessing professional development.

4. Pau A, JeevaratnamK, Chen YS, Fall AA, Khoo C, Nadarajah VD. The Multiple Mini-Interview(MMI) for student selection in health professions training—a systematic review. Med Teach. 2013;35 (12):1027-1041.

6. Boon K, Turner J. Ethical and professional conduct of medical students: review of current assessment measures and controversies. J Med Ethics. 2004;30(2):221-226.

Undergraduate medical education and the foundation of physician professionalism.

미래 의사 선발: 미래 보건의료인력의 핵심(Acad Med, 2013)

Selecting Tomorrow’s Physicians: The Key to the Future Health Care Workforce

Kelly E. Mahon, MA, Mackenzie K. Henderson, and Darrell G. Kirch, MD

최극 미국 내 의료혁신은 세 가지 목적을 가지고 있다. 하나는 개개인의 건강을 향상시키는 것, 둘째는 인구집단의 건강을 향상시키는 것, 그리고 마지막으로 비용을 낮추는 것이다. 이 목적을 달성하기 위해서 전통적으로 '자율성'을 바탕으로 진료를 해왔던 의사들은 점차 팀-기반 진료 모델의 구성원이 될 것을 요구받고 있다.

Recent health care reform efforts in the United States have focused on the “triple aim”1 of improving health care for individuals, improving population health, and lowering costs. Physicians, who traditionally have practiced with considerable autonomy, will be required to become members of the team-based patient care models that are necessary to achieve these goals

의과대학 입학: 역사적 유물

Medical School Admissions: A Historical Legacy 

플렉스너가 20세기 초반, 북미 전역에 걸쳐 의과대학을 평가했을 때, 의학전교육요건(premedical education requirements)과 의과대학 입학절차가 부실하다는 점을 지적했다. 이는 미국에 기준에 미달하는 의과대학들이 횡행하는 이유이며 "의학교육과 의료에 전례없는 해를 끼칠 수 있는 토양"이라고 묘사했다.

When Flexner traveled across North America in the early 20th century, he decried the lack of rigor in premedical education requirements and medical school admission processes, describing the proliferation of substandard medical schools in the United States as “the fertile source of unforeseen harm to medical education and to medical practice.”3 

플렉스너 보고서의 중요한 유산 중 하나는, 미래 의사가 최소한의 기초과학 지식을 갖춰야 한다는 것이다.

The key enduring legacy of the Flexner Report is its argument that future physicians should possess a minimum threshold of knowledge in the basic and natural sciences.4 

MCAT시험은 의과대학지원자의 과학지식에 대한 성취 정도를 평가할 뿐 아니라, GPA와 더불어 의과대학에서의 성적, 의사면허시험에서의 성적을 예측하는 도구로 활용되어 왔다.

The MCAT exam has become the tool of choice not only to measure medical school applicants’ mastery of scientific content, in conjunction with their grade point averages, but also to act as a reliable predictor of success in medical school and initial licensure examinations.5 

오랫동안 의과대학 지원자를 GPA나 MCAT 점수를 넘어선 어떤 기준에 의해서 평가해야 한다는 열망이 있었으며, 1980년대 초반에는 의과대학 지원자를 단순한 예비 학자가 아니라 하나의 인간으로서 평가하는 live interview가 등장하였다. 최근 면접이 개선됨에 따라 면접이 스크리닝 도구로서 강점을 가지게 되었음에도 불구하고, 면접은 전통적으로 약하고, 주관적이고, 비일관된 도구라고 인식되어 왔다.

There long has existed a clear need to assess applicants beyond their grades and MCAT scores. By the early 1980s, live interviews emerged as a tool to help admissions officers get to know an applicant as a person and not merely as a scholar.6 Although recent innovations, as we will discuss below, are showing great promise to strengthen the interview as a screening tool,7 interviews traditionally have been a relatively weak, subjective, and inconsistent means by which to assess medical school applicants.8

미래 의료인력 선발: 의료 혁신의 핵심

Selecting the Future Physician Workforce: A Key to Health Care Reform

플렉스너의 연구 결과에 따라서 만들어진 입학 시스템이 20세기와 21세기 의사들이 전통적인 자연과학 분야의 튼튼한 토대를 갖출 수 있도록 성공을 거둬온 것은 사실이다. 그러나 이는 역설적으로 보건의료 시스템을 변혁할 수 있는 혁신적 의사를 찾아내는데는 약점을 보여왔다.

Although the admission system created in response to Flexner’s findings has been successful in ensuring that 20th- and 21st-century physicians are grounded in the natural and traditional life sciences, it has fallen short in identifying the innovative physicians who can transform the health care system.

의과대학 입학에 대해 생각할 때 몇 가지 함께 고려할 요인이 있다.

Several major factors have converged to influence thinking about medical school admissions. 

• national debate surrounding health care reform 
• passage of the Patient Protection Affordable Care Act— 
• issues regarding professionalism 

전인적 학생선발

Supporting Holistic Admissions

Holistic admissions, an integral component of the AI, refers to a “flexible, highly individualized process by which balanced consideration is given to the multiple ways in which applicants may prepare for and succeed as medical students and doctors.”24

This process complies with the U.S. Supreme Court’s “holistic review” rubric, which was established in 2003 by Grutter v. Bollinger, and calls for an individualized review of each applicant that considers how that applicant might contribute to a diverse educational environment. Evaluation criteria for a holistic review process must be mission driven, broad based, institution-specific, and applied across the applicant pool consistently.25 Holistic review has three goals: 

• to assess applicants’ academic readiness for medical school, 
• to identify and assess applicants’ interpersonal and intrapersonal competencies, and 
• to encourage diversity in medical education.

학업 준비도 재정의

Redefining academic readiness

의학교육에서의 역량 정의

To define medical education competencies, two working groups identified the skills and knowledge that future physicians should possess on entry to or completion of medical school. 

• Issued in 2009, “Scientific Foundations for Future Physicians” 
• The companion report, “Behavioral and Social Science Foundations for Future Physicians,”

최근 AAMC와 다른 다섯개의 협회가 IPEC를 구성

More recently, the AAMC and five other health associations representing schools of osteopathic medicine, dentistry, nursing, pharmacy, and public health jointly created the Interprofessional Education Collaborative (IPEC).

여기서는 전문가-간-역량을 정의하고 보고서 발간

This group initially defined four interprofessional competencies that health professions students should acquire over the course of their training: 

• values and ethics, 
• understanding roles and responsibilities, 
• interprofessional communication, and 
• teamwork. 

The result of IPEC’s efforts, “Core Competencies for Interprofessional Collaborative Practice,” represents the first time consensus has been reached about competencies required for team- based practice in a variety of settings, including in the clinic and at the bedside.27

MCAT이 현재 의과대학생 선발에서 중요한 도구로 사용되고 있기에 MR5는 2015년부터 MCAT의 개선된 버전을 사용할 것을 권고하였다. 가장 큰 변화는 행동과학, 사회과학 개념이 포함된다는 것이다.

In recognition of the MCAT exam’s status as an important tool for medical student selection,2 the fifth MCAT review (MR5) committee recommended, and the AAMC Board of Directors approved in February 2012, revisions to the MCAT exam beginning in 2015.19,28–30 One of the most prominent changes is that the 2015 exam will add a section that tests knowledge of concepts from the behavioral and social sciences to complement testing in the basic and natural sciences.31

내적 역량과 대인관계 역량 도출 및 평가

Identifying and assessing interpersonal and intrapersonal competencie

전인적 평가의 두 번째 목표는 전인격을 갖춘 의사가 될 학생을 찾아내는 것이다. AAMC는 바람직한 역량을 아래와 같이 도출했다.

Holistic review’s second goal is to identify applicants who possess the traits, experiences, and attributes that will lead them to become well-rounded physicians. In 2013, the AAMC identified the most desirable interpersonal and intrapersonal competencies for entering medical students34,35 (see Table 1).

두 번째는 SJT를 활용하여 평가하는 것이다. SJT는 다음과 같은 것이다.

Secondly, the AAMC is exploring the development of a situational judgment test (SJT) as another tool to probe applicants’ interpersonal and intrapersonal competencies.39 SJTs, which “confront applicants with written or video-based scenarios and ask them to indicate how they would react by choosing an alternative from a list of responses,” have shown great promise in identifying interpersonal skills.40

앞에서 말한 바와 같이 새로운 면접 기술이 등장하고 있으며 MMI는 멕마스터 의과대학에서 처음 도입되어 대부분의 캐나다 의과대학과 미국 의과대학 중 22개 이상의 의과대학에서 활용중이다.

As mentioned earlier, new interview techniques are emerging to allow medical schools to probe better dimensions of applicants’ competencies, ranging from how applicants respond to novel situations to their reactions to an ethical conflict. The multiple mini-interview (MMI) was pioneered by the Michael DeGroote School of Medicine at McMaster University and is now employed by the majority of Canadian medical schools and more than 22 U.S. medical schools.7,39

의학교육의 다양성 지탱하기

Supporting diversity in medical education

이러한 변화는 미래의 의사들이 높은 수준의 문화적 역량을 갖출 것을 요구할 것이며 이는 다음과 같이 정의된다.

This change will require that tomorrow’s physicians possess a high degree of cultural competence, which has been defined as “a set of congruent behaviors, knowledge, attitudes, and policies that come together in a system, organization, or among professionals that enables effective work in cross-cultural situations.”43

Page는 다양한 배경에서 온 다양한 사람으로 이뤄진 그룹이 문제해결을 더 잘 잘하며, 어떤 개개인보다도 뛰어나다는 것을 보여주었다. 또한 추가적으로 의과대학생들은 같은 의대생들의 다양성을 가치롭게 생각하며, 학업경험은 물론 환자를 보는 경험 역시 이 다양성에 의해서 향상된다고 평가했다.

Page44 has shown that diverse groups of people from varied backgrounds do better at problem solving and, in many ways, are smarter than any individual. Further evidence shows that “students in medical schools value diversity in their classmates and find both the academic experiences and their abilities to work with patients from differing backgrounds enhanced by this diversity.”45

100년 전, 의과대학은 표준화된 시험을 통해서 과학적 배경이 잘 갖춰진 학생을 선발하였으며, 이것이 플렉스너 보고서에서 드러난 문제를 해결하는 확실한 방법이었다. 그러나 100년이 지난 지금, 환경은 변하고 있다.

A century ago, the academic medicine community concluded that providing physicians with a rich scientific background, verified through the use of standardized tests, was the definitive answer to addressing the problems revealed by the Flexner Report. As the last 100 years have demonstrated, however, changing circumstances in the health care landscape necessitate constant transformation.

23 Swick HM. Toward a normative definition of medical professionalism. Acad Med. 2000;75:612–616. 

24 Addams AN, Bletzinger RB, Sondheimer HM, White SE, Johnson LM. Roadmap to Diversity: Integrating Holistic Review Practices Into Medical School Admission Processes. Washington, DC: Association of American Medical Colleges; 2010. https://members.aamc.org/eweb/upload/ Roadmap%20to%20Diversity%20 Integrating%20Holistic%20Review.pdf. Accessed August 21, 2013.

25 Witzburg R, Sondheimer H. Holistic review: Shaping the profession of medicine one applicant at a time. N Engl J Med. 2013;368:1565–1567. http://www.nejm.org/ doi/pdf/10.1056/NEJMp1300411. Accessed August 21, 2013.

38 Association of American Medical Colleges. Letters of evaluation guidelines. https://www.aamc.org/ initiatives/admissionsinitiative/332572/ lettersofevaluationguidelines.html. Accessed August 21, 2013.

27 Interprofessional Education Collaborative Expert Panel. Core Competencies for Interprofessional Collaborative Practice: Report of an Expert Panel. Washington, DC: Interprofessional Education Collaborative Expert Panel; 2011. http://www.aacn.nche. edu/education-resources/ipecreport.pdf. Accessed August 21, 2013.

Selecting tomorrow's physicians: the key to the future health care workforce.

3년제 의과대학의 장점과 과제: 근거 중심 토론 (Acad Med, 2015)

The Merits and Challenges of Three-Year Medical School Curricula: Time for an Evidence-Based Discussion

John R. Raymond Sr, MD, Joseph E. Kerschner, MD, William J. Hueston, MD, and Cheryl A. Maurana, PhD

최근의 3년제 의과대학에 대한 관심은 2025년까지 46,000명에서 90,000명의 의사가 부족할 수도 있다는 예상과, 의과대학생들의 빚이 점차 늘어나고 있다는 것으로부터 촉발되었다. 3년제 의과대학 프로그램은 여러 논문과 언론에서 논쟁이 되온 바 있다.

The recent resurgence of interest in three-year medical school curricula has been driven by a projected shortage of 46,000 to 90,000 physicians by 20251,2 and by mounting medical student debt. Three-year programs have been the subject of spirited debate in the peer-reviewed medical literature,3–7 the mainstream press,8–10 and online publications.11

앞서 이야기된 바와 같이 의사가 부족할 것이라는 예측과 의과대학생의 빚이 늘어나고 있다는 주요한 이유 외에도, 일부 레지던트 프로그램 디렉터과 일부 의학교육 리더들은 현재와 같은 의과대학 교육 구조에서 4학년의 가치가 무엇인가에 대한 의구심을 표한다. 실제로 1990년 Robert Petersdorf는 "현재의 4학년은 세계 각 국을 여행다니는 기회이거나 임상실습을 구실로 한 오디션에 불과하지 않는다"라고 지적했다. 더 최근에는 AOA와 AACOM의 blue-ribbon commission은 "정해진 몇 달을 채워야 하는 교육이 아니라 역량을 성취하는 것에 기반한 새로운 교육 모델이 필요하다"라고 권고했다. 

In addition to citing the growing education debt burden and projected physician shortages as primary reasons to support three-year medical school curricula, proponents note that some residency program directors12 and some medical education leaders have questioned the value of the fourth year of medical school as currently structured. Indeed, in 1990 Robert Petersdorf,13 then president of the Association of American Medical Colleges, commented that “the present fourth year … turns out to be nothing more than a chance to travel about the country or to engage in audition clerkships.” More recently, a blue-ribbon commission of the American Osteopathic Association and the American Association of Colleges of Osteopathic Medicine recommended creation of “a new education model that is based on achievement of competencies without a prescribed number of months of study.”14

3년제 교육과정에 대해 우려를 표하는 사람들은 다음과 같은 것을 걱정한다.

Individuals concerned about three-year curricula cite potential problems such as 

• student burnout, 
• faculty fatigue, 
• the increasing complexity of medicine, 
• quality issues, and 
• diminished competitiveness for residencies.15–18

간결성을 위해서 우리는 3년제- 4년제- 모델이라고 지칭하지만, 이 둘 사이의 교육기간 차이는 몇 주 혹은 몇 달 정도이며, 이는 3년제 교육에서는 방학이 상당히 줄어들거나 없어지기 때문이다. LCME는 미국과 캐나다의 MD program이 최소 130주 이상일 것을 요구하나 그 130주의 교육이 제공되는 총 기간에 대해 명시하고 있지는 않다. 이러한 관점에서 3년제 교육과정은 압축되거나/변형되거나/전공의 과정과 통합된 것이라 볼 수 있다.

For brevity, we refer to three- and four- year models, but it is critical to note that the actual differences in contact hours between these types of curricula are measured in weeks or months because of the elimination of summers off and the shortening of vacations and intercessions in typical three-year curricula. The Liaison Committee on Medical Education requires accredited U.S. and Canadian MD-granting programs to include a minimum of 130 weeks of curriculum but does not mandate a time frame over which the curriculum must be delivered.19 For the purposes of this Perspective, therefore, “three-year programs” refers to programs that have been compressed, modified, or integrated with residency training to achieve a three- year medical school graduation goal.

문헌에서 나타난 3년제 교육과정

Three-Year Medical Curricula in the Literature

3년제 교육과정은 새로운 아이디어가 아니다. 여러 문헌에서 1970년대와 1980년대에 미국에는 3년제 교육과정이 여럿 있었으며, 두 개의 캐나다 의과대학은 40년 이상 그러한 프로그램을 운영하고 있다. 이들은 가정의학이나 내과학 전공의 과정을 합하여 3+3 과정으로 운영하면서, 의과대학 4학년을 전공의 1년차로 병합하였으며, 이러한 3년제 프로그램의 학생들이 4년제 프로그램 학생들과 거의 모든 단계에서 비슷한 수행능력을 보여준다는 것을 제시했다.

The three-year medical school curriculum is not a new idea.17,20,21 The broad array of published works—from U.S. medical schools that had three-year programs in the 1970s and 1980s, from two Canadian medical schools with more than four decades of experience with such programs, and from family medicine and internal medicine 3 + 3 programs, which allow medical students to accelerate their medical education by combining their fourth year of medical school with their first year of residency—suggests that students in three-year programs perform as well as their four-year counterparts at all stages of their careers.

1970년대와 1980년대의 미국 의과대학

U.S. medical school experiences in the 1970s–1980s

전통적인 플렉스너의 의학교육 모델은 약 100년간 거의 그대로 자리를 지켜왔고 2년의 전임상실습 교육과 2년의 임상실습 교육으로 구성되었다. 아브라함 플렉스너가 이 모델을 권고할 때는 의과대학 교육과정이 의사 수련의 거의 전부였다. 즉, 전공의 교육을 할 수 있는 프로그램이 거의 없었다. 그러나 오늘날 의사 양성 과정은 3~4년이 아니라 7년에서 10년까지 걸린다.

The traditional Flexnerian model of medical education has remained largely unchanged for more than a century, with students sequentially mastering two years of preclinical classes followed by two years of clinical clerkships.22 When Abraham Flexner recommended this model, medical school was the extent of most physicians’ training—there was little availability of residency training programs. Today, however, becoming a physician is not a three- or four-year proposition but, rather, a 7- to 10-year journey with medical school comprising the first step.

In the United States, the four-year model was modified out of necessity during World War II, when physicians were trained in less than three years.23,24 The four-year model also was challenged in the 1970s when three-year curricula were created in response to a perceived physician shortage and were fueled by the availability of federal capitation funding through the Comprehensive Health Manpower Training Act of 1971 (Public Law 92-157). In 1973, nearly 25% of U.S. medical schools offered three-year programs,7,25 with enrollment in these programs peaking at about 2,600 students in 1973–1974.24

그러나 이러한 3년제 프로그램은 빠르게 소멸되어 결국 사라지게 되었는데, 이는 재정 지원이 중단되었을 뿐 아니라, 의사 부족에 대한 우려도 점차 줄었고, 이러한 3년제 교육과정의 속도와 강도에 교수들이 전반적으로 불만을 품었기 때문이다. 그러나 학생들은 대체로 만족해왔다. 또한 3년제든 4년제든 대부분의 연구 결과에서는 그 졸업생들의 수준에 별다른 차이가 없다는 것도 눈여겨 볼 만하다.

These three-year programs waned rapidly, however, and eventually disappeared. Their demise was due to the discontinuation of capitation funding, declining concern about physician shortages, and broad-based faculty dissatisfaction with the pace and intensity of such programs.15,18,24 Students, however, generally were satisfied with their experiences.25 It is noteworthy that, despite faculty concerns, most studies showed no significant differences in the academic or clinical performances of the graduates of three-year and four-year programs.26–30

More contemporary evidence suggests that students can master the medical school curriculum in three years.

In Canada, the Michael G. DeGroote School of Medicine at McMaster University (McMaster) and the Cumming School of Medicine at the University of Calgary (Calgary) have experience with three-year curricula that spans more than four decades. The McMaster and Calgary three-year programs deliver their competency-based curricula focused on clinical experience and learning in context in 130 weeks and 131 weeks, respectively.

Neufeld and colleagues37 reviewed the McMaster experience through 1989. They found that McMaster graduates were comparable to four-year graduates of U.S. and Canadian medical schools in terms of 

• performance on standardized national examinations, 
• preparation for and performance during residency, 
• ability to obtain preferred first-year residencies, and 
• percentage pursuing primary care. 

Interestingly, they also found that McMaster graduates were more likely 

• to pursue academic careers compared with graduates of four-year medical schools. 
• A survey of faculty attitudes at McMaster regarding the three-year curriculum demonstrated satisfaction.38

가정의학, 내과학 연계 프로그램 

Accelerated family medicine and internal medicine program experiences

1980년대와 1990년대에 약 25개의 미국 의과대학이 의과대학 4학년 대신 가정의학 전공의 과정과 연계한 3+3 프로그램을 운영하였다. 그러나 GME 인정 이슈때문에 결국 사라졌다.

In the 1980s and 1990s, approximately 25 U.S. medical schools offered accelerated family medicine programs that allowed students to begin residency training while finishing their fourth year of medical school. These 3 + 3 programs eventually were terminated because of unresolved graduate medical education (GME) accreditation issues.

연구를 살펴보면 이러한 과정의 학생이 4년제 학생에 뒤지지 않는다.

Studies39–43 showed performance of students in these programs to be comparable to that of students in traditional four-year curricula

New York Medical College and St. Vincent’s Catholic Medical Centers of New York 의 비교연구

A study of such a curriculum at New York Medical College and St. Vincent’s Catholic Medical Centers of New York compared six classes of residents who had completed internal medicine training from 1995 to 2000. Graduates of the accelerated program were comparable to graduates of the traditional program

따라서 가정의학과 내과 연계 프로그램은 수행능력을 손실시키지 않고도 수련 기간을 단축하는 효과가 있다. 

Thus, accelerated family medicine and internal medicine programs have been shown to reduce training time without degradation of performance. Although not directly comparable, students in six-year baccalaureate–MD programs have been found to perform as well as traditional students on board examinations.46

미국에서 등장하고 있는 3년제 교육 프로그램

Emerging Three-Year Medical School Programs in the United States

다양한 3년제 모델이 등장하고 있다.

A rich variety of three-year medical school curriculum models is emerging in the United States (Figure 1). 

이 모든 프로그램들은 일정부분 역량바탕 평가를 하고 있다.

All of them focus to some degree on competency- based assessment and advancement of students.

• Lake Erie College of Osteopathic Medicine (LECOM) in 2007 initiated the Primary Care Scholars Pathway (PCSP), a three-year curriculum for students committing to family medicine. (...) In 2011, LECOM began the Accelerated Physician Assistant Pathway (APAP), a customized three-year medical school track for practicing physician assistants.
• Columbia University College of Physicians and Surgeons in 2013 began a three-year Fast-Track MD program, which admits up to four students holding life science PhDs each year.51
• Mercer University School of Medicine in 2010 initiated the Accelerated Track in Family Medicine on its Savannah campus.
• Texas Tech University Health Sciences Center began its Family Medicine Accelerated Track (FMAT) in 2011.
• The New York University (NYU) School of Medicine began a three- year track in 2013.
• The University of California Davis School of Medicine, in partnership with Kaiser Permanente Northern California, matriculated six students into a three- year Accelerated Competency-Based Education in Primary Care (ACE-PC) program in 2014.
• The Louisiana State University School of Medicine is planning a three-year program in partnership with the University of Louisiana–Lafayette.58
• Our institution, the Medical College of Wisconsin, matriculated 26 students in 2015 to a three-year program at our new Green Bay regional campus, and plans for 20 to 25 more per class to a three-year program at our Central Wisconsin campus in 2016.

많은 사람들이 3년제 프로그램이 성공적으로 도입될 만큼 미국 내 환경이 충분히 바뀌었는지 물어본다. 이에 대해 우리는 위에서 언급한 프로그램들이 그 규모(정원)가 작고, 특정 그룹의 학생을 대상으로 하고 있다는 것을 말하고 싶다. 향후 면밀한 검토가 필요하다.

Some may ask whether circumstances have changed sufficiently to enable successful implementation of three- year medical education programs in the United States. We note that the programs described above are small in scale and involve a limited number or niche group of students rather than the entire student body. Thus, these new programs should be studied carefully.

3년제 교육과정의 장점

Potential Advantages of Three- Year Medical School Curricula

유사하게, 3년제 교육과정은 의사과학자로서의 진로를 고려하는 학생들에게도 적용할 수 있다. 예컨대 Columbia의 Fast-Track MD 프로그램은 학생들이 자연과학의 PhD를 할 수 있도록 의과대학 과정을 3년에 마무리짓게 해준다.

Similarly, three-year programs could provide pathways into medicine for scientists whose training and experiences overlap with the basic science component of the medical school curriculum. For example, as described above, Columbia’s Fast-Track MD program allows individuals with PhDs in life science disciplines to complete medical school in three years.51

학생들의 빚 축소와 빠른 임상경험

Reduced education debt burden and more rapid entry into clinical practice

3년제 프로그램은 학생들의 빚을 줄여주고 임상경험을 더 쌓을 수 있는 추가적인 시간을 제공한다. 2012-2013학년도에 의과대학 졸업생들의 평균 빚은 17만 달러였다.

It has been discussed widely that three- year programs could reduce lifetime student debt burden and provide an opportunity for an additional year of productive clinical practice. For the 2012–2013 academic year, the mean education debt for graduating medical students in the United States was over $170,000.59

의과대학 교육에 새로운 기회 창출

Creation of opportunities to enrich medical school education

3년제 프로그램은 단순히 교육과정을 빠르게 만드는 것이 아니다. 이는 4학년 시기를 자신의 진로 (석사 학위와 같은)에 맞게 사용할 수 있게 해준다. 예컨대 MPH 학위와 같은 것이 일차의료나 공공의료를 원하는 학생들에게 제공될 수 있다. MBA나 역학, 보건행정, 공공정책 등도 가능하다.

Three-year medical school curricula are not simply accelerated pathways to primary care residency and practice. They also could provide opportunities for students to use the fourth year to obtain training relevant to their chosen careers, perhaps through master’s degree programs. For example, a master of public health degree would provide opportunities for students who want to work at the interface of primary care and public health. Other relevant master’s degree programs include business administration, epidemiology, health care administration, and public policy.

어떤 사람들은 의과대학 4년의 구조가 거의 대부분에 존재하고, 연구 일렉티브, 서브인턴십, 연구참여, 구직 면접, 회복기간 등으로 활용되는 것에 의문을 표한다. 많은 학생들이 일렉티브를 전공의에 선발되기 위한 오디션의 개념으로 참여한다. 분명 이러한 로테이션의 가치가 있긴 하나, 모든 학생들이 해야 할까?

Some have questioned the value of the fourth year of medical school,60 the structure of which has remained fairly similar across time and institutions and typically offers clinical and research electives, subinternships, research experiences, job interviews, and “recuperation” time. Many students forgo electives to “audition” for residencies during their fourth year. Certainly, these rotations have value, but do all students need the fourth year of medical school? It

의사가 아닌 보건의료인과 과학자의 진로 변환

Transitional pathways for nonphysician health care providers and scientists

3년제 프로그램이 성공하려면 고려되어야 할 점들이 있다.

There are several key considerations that should be addressed to ensure success. 

• Institutions with three-year curricula should choose their matriculants wisely and seek student input to optimize these programs. 
• They should provide robust support systems for students and deal constructively with burnout. 
• They should develop strong faculty support and faculty development programs to address faculty fatigue and to aid new community-based educators. 
• They should create transition or deceleration pathways for students who are not able to complete the accelerated curriculum within three years. 
• Finally, they should cultivate relationships with residency programs or create their own destination residency programs for students in their three-year curricula.

33 Dienstag JL. Evolution of the New Pathway curriculum at Harvard Medical School: The new integrated curriculum. Perspect Biol Med. 2011;54:36–54.

Acad Med. 2015 Aug 11. [Epub ahead of print]

The Merits and Challenges of Three-Year Medical School Curricula: Time for an Evidence-Based Discussion.

비판적 사고를 비판적으로 바라보기: 능력인가 기질인가? (Med Educ, 2011)

Thinking critically about critical thinking: ability, disposition or both?

Edward Krupat,1 Jared M Sprague,2 Daniel Wolpaw,3 Paul Haidet,4 David Hatem5 & Bridget O’Brien6

의학교육의 성과에 대해서 이야기할 때 비판적 사고는 흔히 나오는 주제 중 하나이다. 그러나 'critical thinking'이라는 용어 자체는 LCME에도 ACGME에도 GMC에도 CanMEDS에도 나오지 않는다.

When discussing the desired outcomes of medical education, it is common for educators to voice the hope that their graduates will excel at critical thinking. However, for all the rhetoric directed toward this topic in academic medicine, the actual term ‘critical thinking’ is not once mentioned in the accreditation standards of the US Liaison Committee on Medical Education (LCME),1 the six competencies of the US Accreditation Council for Graduate Medical Education (ACGME),2 the outcomes and standards for undergraduate medical education of the UK General Medical Council (GMC) 3 or the CanMEDS doctor competency framework.4

반면 AACU는 CT를 중등교육 이후 교육에서 다루어야 할 주요 지적, 실용적 기술이라고 했으며, NLN은 CT를 학사과정 수준에서 반드시 길러야 할 필수 요소로 보았다.

By con- trast, the Association of American Colleges and Universities5 lists critical thinking as one of the major intellectual and practical skills to be fostered by post- secondary education and the National League of Nursing has identified critical thinking as an essential component of baccalaureate-level education that must be fostered and assessed as a criterion for continuing accreditation.6

의학 인증기준과 목적에서 CT에 대한 명확한 레퍼런스가 없는 것은 그것과 의미가 중복되는 보다 구체적인 용어를 사용하기 때문이다. LCME는 critical judgement, GMC는 critically evaluate- 등의 용어를 사용한다.

The absence of formal reference to ‘critical thinking’ in medical accreditation standards and goals can be partially accounted for by the adoption of more specific reference terms that have a clear overlap, such as the LCME’s interest in ‘critical judgement’ and the GMC’s expectation that doctors should be able to ‘…integrate and critically evaluate evidence’.1,3

이러한 관심에도 불구하고 CT는 개념적으로 명확하지 않고, 이에 대한 많은 질문에 대한 답도 불명확하다. 

Despite this interest, critical thinking suffers from a lack of conceptual clarity and numerous questions about it go unresolved. 

• Is critical thinking something one is ‘born with’, as has been implied by some commentators for interpersonal skills? 
• If it comes naturally – or if it does not – can it be acquired or enhanced through learning and practice prior to or during medical training? 
• If critical thinking can be ‘taught’, a term that subtly implies a particular perspective on it, how and when should this be done? 
• Where in the curriculum should it appear?15–19 
• And if educators verbally encourage high-level analysis and broad inquiry while instruction and assessment focus on facts and memorisation, do these conflicting messages about critical thinking become part of the hidden curriculum20–22 of medical school?

비판적 사고의 정의내린 문헌들을 보면 넓은 분야를 포괄하고 있다.

A review of definitions of critical thinking reveals a wide range of perspectives. 

Scriven and Paul,23 for instance, have described critical thinking as ‘the intellectually disciplined process of actively and skilfully conceptualising, applying, synthesising, and⁄ or evaluating information…’ 

Kurland24 indicates that critical thinking ‘is concerned with reason, intellectual honesty, and open-mindedness as opposed to emotionalism, intellectual laziness, and closed-mindedness’.

만약 의학교육자들이 좋은 비판적 사고자를 길러내고자 하는데 서로 다른 생각을 하고 있다면, 지원자를 가려내는 방식도, 교육과정에 대한 접근 방식도, 평가에 대한 방식도 다 다를 것이다.

If medical educators state the goal of graduating good critical thinkers with different definitions in mind, it is likely that they will use different methods to screen applicants, apply different curricular approaches to the fostering of critical thinking and devise different approaches to its assessment.

각 대학에서 우리는 의과대학생 교육에 활발하게 참여하면서 다양한 임상에서도 활동하고 있는 교수들을 purposefully sample하였다.

At each school we purposefully sampled doctor faculty members who were both actively involved in medical student education and maintained active clinical practices in a variety of specialties. 

• The former inclusion criterion was used to maximise the likelihood that respondents had previously been involved in thinking or discussion about critical thinking. 
• The latter was used so that the examples given by respondents might be directly rooted in years of observation and direct experience, and derive from a heterogeneous sample of medical perspectives.

질적 내용분석을 수행했다. 어떤 이론이나 프레임워크 없이 시작했으며, 카테고리에 대한 사전에 정해진 생각도 없었다. 대신 답변들을 읽으면서 내용에 따라 카테고리를 만들고 주요하게 드러나는 주제들을 찾아냈다. 

For the multiple purposes defined above, we used qualitative content analysis, a research method that interprets the content of text through ‘the systematic classification process of coding and identifying themes or patterns’.25 Consistent with Hsieh and Shannon’s ‘conventional’ approach,26 we did not start with any guiding theory or framework nor did we have any preconceived ideas about categories into which the definitions might be placed. Rather, we read the responses with the goals of creating coding categories based on content and identifying the predominant themes as they appeared.27 Only one definition, which consisted more of a rambling commentary than a definition, could not be coded.

진행 과정

• We coded respondents’ definitions of critical thinking using an iterative process in which three authors (JMS, EK, BO’B) independently read the same sample of six definitions, proposed categories, and compared, discussed and consolidated lists to create a coding scheme. We then applied the codes to 42 definitions to refine, clarify and finalise the coding scheme and then to reconcile any coding differences in the initial 42 definitions. One author served as the primary coder (JMS) and two others (EK, BO’B) each coded two randomly selected samples of 12 definitions (24 in total) to check for consistency in coding.

• In the first, broader level of analysis, the primary and secondary coders were in agreement in the vast majority of cases. In the relatively few instances in which disagreement occurred, discrepancies concerned whether a definition should be double-coded rather than indicating a lack of consensus about the category into which the definition fell. In each of these cases, consensus was reached through discussion among the coders. 

• These authors (EK, JMS, BO’B) used a similar approach in their coding of the scenarios. After an initial review of the scenarios, the first level of coding,on which this paper primarily focuses, asked if fundamental themes could be found in the scenarios describing critical thinking and those in which it was absent. A more in-depth analysis of the scenarios led us to create a set of categories of specific behaviours described as characterising critical think- ing and a set of behaviours illustrating its absence. 

• Initially, we attempted to code the actions described in the scenarios according to the categories used for the definitions, but found that these categories did not adequately capture the content of the scenarios. Thus, we randomly selected a sample of 12 scenarios and generated a new set of coding categories by having each of the three authors independently generate a list of categories which was then discussed,refined and consolidated. We applied this coding scheme to an additional set of scenarios, discussed and reconciled our coding, and added sub-categories to primary categories as needed. One author (EK) coded all 97 scenarios; a second author (JMS) coded 32, and a third author (BO’B) coded 15 of the scenarios to check for coding consistency. As with the definitions, the coders were in agreement most of the time for the primary coding dimension (which concerned the fundamental differences in the thinking and actions of those described as demonstrating critical thinking and those described as not doing so). In the few incidents of disagreement, the coders reviewed, discussed and reconciled the differences.

Definitions of critical thinking

가장 흔한 정의는 Process에 대한 것

We found three distinct ways in which respondents framed the definition of critical thinking. The most common way of describing critical thinking was as a process (n = 42).

두 번째는 Skill이나 Ability로 보는 관점

Almost as common were those definitions that framed critical thinking as a ‘skill’ or ‘ability’ (n = 40),

Process나 Ability는 Bloom의 기준에 따르자면 고차원적인 정신행동이 포함됨

Both the ‘process’ and ‘ability’ definitions made consistent reference to higher-order mental activities (e.g. synthesis, analysis, interpretation) involved in making sense of information, much like those described by Bloom.28

세 번째 종류는 개개인의 특질(trait)이나 습관(habit)으로 보는 것.

The third type of definition stood out as very different in character in that it referred to characteristics of the individual, personality traits or habits of mind rather than to process or ability. We refer to these as dispositional definitions.

혼합된 정의를 내린 사람도 있음.

Examples of hybrid definitions follow. The first of these describes a combination of process and dispo- sitional definitions and the second refers to a com- bination of disposition plus ability:

Manifestations of critical thinking in clinical practice

다수의견

In the cases they provided, the vast majority of respondents described biomedical clinical challenges that involved formulating diagnoses or making treat- ment decisions. 

소수의견

However, a minority of respondents described, alone or in combination with standard biomedical challenges, scenarios that involved efforts...

• to activate and engage patients, 
• to assure patient safety, 
• to deal with ethical or professional challenges, or 
• to resolve conflicts around the use of limited resources.

The presence of mindful and self-reflective behaviour emerged somewhat more strongly in the scenarios than in the definitions.

Manifestations of the absence of critical thinking in clinical practice

위와 단순 반대되는 사례도 있었으나 완전히 다른 것도 있었음.

Although some descriptions of doctors who did not exhibit critical thinking were exact opposites of the above, the majority of these characterisations were notably different.

Numerous instances were offered in which doctors failed to look beyond the obvious and demonstrated behaviour that was neither self-aware nor self-critical.

Although not common, the absence of critical thinking sometimes reflected a poor knowledge base or an inability to manage complexity (‘…would not be able to produce a broad differential...cannot analyse the available information to determine the correct diagnosis’). 

In the vast majority of scenarios, however, questions about knowledge or skills did not arise because the clinicians described acted by rote, failed to look beyond the obvious, neglected to collect adequate information or made overly quick decisions.

Discussion

이 연구의 추동력: CT에 대한 다양한 관점, 합의의 부재, 이런 것으로 인한 생산적 토론의 어려움

The impetus for this project grew out of the casual observation that many differing viewpoints about critical thinking exist, and the belief that this unacknowledged lack of consensus constitutes a major block to productive discussion and the development of successful strategies to foster and assess critical thinking.

CT를 세 가지 다른 식으로 정의내리고 있었음.

In this study, clinician-educators defined critical thinking in three different ways. The two predominant perspectives, which focus on process and ability, have a great deal of overlap. 

• Process: The former describes what critical thinking entails (the processes of syn- thesis, analysis, etc.), 
• Ability: whereas the latter extends this definition a step further by indicating that engaging in these processes involves some form of ability. 
• 이렇게 정의내릴 때는 가르칠 수 있다고 생각한다는 의미
  Defining critical thinking as an ability suggests that, like other skills and abilities, it can be ‘taught’ and ‘learned’ through some form of instruction. 
• Disposition: By contrast, conceptualising critical thinking as a disposition has very different implications about what lies at its heart, where it comes from and whether it is appropriate to conceive of it as a ‘teachable skill’.
• 이렇게 정의내릴 때는 가르칠 수 있는지에 대해서 관점이 다름

Ability-Disposition의 구분은 Teaching-as-transmission과 Teaching-as-enculturation의 차이이기도 하다.

The ability-disposition distinction highlights the difference between teaching knowledge and skills, referred to as teaching-as-transmission, versus teaching attitudes, modifying personality and changing behaviour, referred to as teaching-as-enculturation.29,30 

지식을 준다고 향상되지 않는 것들이 있다. Dispositional 한 관점에서는 정보를 주거나 사실을 바로잡아 주는 것과는 다른 접근이 필요하다.

Traits such as open-mindedness, flexibility and curiosity are not likely to be increased by giving people knowledge to absorb or cognition-based tasks to master. According to the dispositional perspective,we would foster critical thinking by 

• encouraging self-awareness and mindfulness, 
• modelling open discussion and inquiry, 
• accepting doubt and uncertainty, and 
• encouraging students to value the activity of asking the right questions, 

rather than giving them information or assessing them according to the factual correctness of their answers. 

disposition 관점에서 대답한 의사의 수는 매우 적어서 시나리오가 아니었다면 이러한 정의는 주석에 그칠 뻔 했다. 그러나 시나리오에서 의사들은 CT를 다양한 범위의 기술과 disposition으로 묘사했다.

Because so few of the participating doctors used the dispositional interpretation in their definitions, it would represent little more than a footnote were it not for the content of the scenarios. In the scenarios, clinicians demonstrating critical thinking were described as demonstrating a range of desirable skills and dispositions:

시나리오에서 드러난 CT를 하지 않는 의사의 모습. 인지적 수전노(cognitive miser)처럼 행동한다. 문제를 푸는데 인지적 노력을 거의 들이지 않고 지름길만 찾음.

The pattern of behaviours described for those who did not exhibit critical thinking was clear and consistent, but quite different. These doctors typically acted as ‘cognitive misers’,31 a term used by social psychologists to describe people when they take mental shortcuts and engage in heuristic thinking, thereby expending the minimum cognitive effort necessary to solve a problem.

Perkins의 '좋은 사고'에 대한 프레임워크. 

the triadic framework offered by Per- kins et al.32,33 provides a conceptual scaffolding upon which all of the responses can be placed. The conceptual framework described by Perkins et al.,32,33 which they call ‘good thinking’, was developed completely outside of medicine; however, it encom- passes virtually all of our findings. Perkins et al.,32,33 propose that good (i.e. critical) thinking requires three elements: 

(i) sensitivity; 

(ii) inclination, and 

(iii) ability. 

각 요소는 그 이전 단계의 요소가 없다면 불가능하거나 무관해진다.

Without each prior element, the next becomes impossible or irrelevant.

In most instances, however, the clinicians described as not thinking critically in our respondents’ scenarios failed to demonstrate one of the first two elements rather than the third.

CT가 잘 발휘되기 위해서도 위의 세 가지 요소는 마찬가지이며, 다만 피로나 시간의 압박 같은 상황적 요인들이 CT의 발현을 억제할 수도 있긴 하다.

However, according to Perkins et al.,32,33 in order for cognitive processes and abilities to become relevant, we must first presume that sensitivity and inclination have been satisfied. If students and doctors do not have sufficient self-awareness of and sensitivity to complexity, and unless they are motivated not to settle for the obvious and are willing to commit the effort required to engage in the work of critical thinking, their knowledge, skills and abilities may never come into play. Parenthetically, it is interesting to note that although situational factors such as fatigue and time pressure play significant roles in exacerbating tendencies toward imperfect information processing,38–41 the non-critical thinking clinicians in the scenarios were almost never characterisedas being rushed or tired. 

입학, 교육, 평가에 대한 함의

In light of the model described by Perkins et al.,32,33 we believe that the findings have potentially broad implications for medical school admissions, curricu- lum and assessment protocols. 

• 첫째, CT를 세 가지 중 무엇으로 볼 것이냐? 입학때 스크리닝 해야 할 것인가?
  First, we can ask whether critical thinking, as a personal predisposition or a cognitive ability, should be considered as part of the admissions and screening process for prospective medical students.

• 보다 복잡성과 불확실성을 포용하게 해야함.
  Second, the model proposed by Perkins et al.32,33 suggests that teaching cognitive skills to students who lack sensitivity and inclination is not likely to bring about the desired results. To foster critical thinking, and thereby good clinical reasoning, we should teach students to embrace complexity and be open to uncertainty, rather than to shy away fromor eliminate these issues.

• 평가방법때문에 misguide될 수 있음.
  Third, our current assessment methods may also be misguided in that they place students in testing situations that focus almost exclusively on cognitive skills and leave little space in which sensitivity or in clination might manifest themselves.

Thinking critically about critical thinking: ability, disposition or both?

TBL 촉진의 12가지 팁(Med Teach, 2015)

Twelve tips for facilitating team-based learning

CHARLES GULLO, TAM CAM HA & SANDY COOK

TBL의 기원은 1970년대 후반 오클라호마 대학의 Larry Michaelsen 교수로 거슬러 올라간다. 이후 다양한 교육 세팅에서 활용되었다. Larry Michaelsen 교수는 경영 대학원 교육에서 활용했지만, 이제는 미국 전역에 걸쳐서, 그리고 많은 의과대학에서 사용중이다. (Duke-NUS의 사례). TBL의 이점은 매우 많으며 여러 문헌에 잘 정리되어 있다.

Team-based learning (TBL) traces its roots to Professor Larry Michaelsen at the University of Oklahoma, United States (USA) in the late 1970s. Since then, it has grown to become a popular and effective instructional strategy used in a number of different educational settings (Koles et al. 2010; Parmelee & Michaelsen 2010a; Kamei et al. 2012; Fatmi et al. 2013). Although Michaelsen implemented it in graduate business instruction, it has more recently been used as a major teaching platformby a number of different educational programs across the United States (Team-Based Learning Collaborative 2013) and in a number of medical schools (Thompson et al. in 2007a,b). 

At the Duke-NUS Graduate Medical School Singapore, we have been using this teaching methodology since 2007 as a primary mode of learning for our students during their pre-clinical instruction (Kamei et al. 2012). 

The benefits of this teaching methodology are numerous, and have been well-documented in a number of sources (Hunt et al. 2003; Zgheib et al. 2010; Sisk 2011; Fatmi et al. 2013; Hazel et al. 2013).

단순해 보이는 절차이지만 팀간 토론의 효과를 극대화 하기 위해서는 효과적인 촉진법이 필수적이다. 그러나 이것은 TBL에서 가장 어려운 부분이기도 하다.

While a seemingly simple process, the heart of creating an engaging and impactful inter-team discussion is an effective facilitation. Yet, effectively facilitating these discussions can be one of the most challenging aspects of TBL.

또한 TBL에서 팀의 참여를 위해 촉진이 필요한 부분은..이런 것들이다. 

TBL’s added challenges for inter-team engagement, 

• 모든 학습자가 참여하고 책임을 지게 함 keeping all learners engaged and accountable, 
• 수업 시간에 답을 이끌어냄 eliciting the answers from the class, and 
• 교수자가 답을 주기 전에 학생의 이해와 가설 설정을 유도함 challenging learners understandings and assumptions (before revealing the faculty’s answer).

TBL에서 직접적 촉진이 일어나는 부분은 세 곳 있다. 첫 번째는 TRAT 이후(TRAT 중간에는 관여하지 않아야 한다) 이며, 여기서 교수자는 학생들의 잘못된 이해를 밝혀내고, 촉진자의 관여가 없는 상태에서 발생한 잘못된 개념을 바로잡고, 정답을 밝혀준다.

There are three places where directed facilitation occurs in TBL (Figure 1). The first place that a facilitated discussion occurs is after (and importantly not during) the teamreadiness assurance test (TRAT). This facilitated discussion requires faculty to be able to drawout the misunderstandings or resolve any misconceptions not addressed by the non-facilitated inter team TRAT discussion and reveal ‘‘correct’’ answers.

• 하나는 RAT과 적용 단계는 모두 assimilative learning을 유도하기 때문이며, 이는 새로운 정보를 기존에 존재하는 지식 구조에 병합하는 과정이다. 
• 또한 transformative learning이기도 한데, 이 과정은 비판적 사고를 통해 기존의 지식 구조를 변화시키는 과정이다.

Creating the right environment

4S에 기반하여 문제를 낸다.

Ti p 1 Use the 4S’s to craft engaging questions

실제와 관련된/중요한 문제, 모든 학생이 동일한 문제, 단 하나의 선택을 내린 후 근거를 대도록, 동시에 결과를 발표하도록

Using the four S’s of application writing and development (significant problem, same problem, specific choice, and simultaneous report) can also ensure maximal participation and active engagement during the application phase (Parmelee & Michaelsen 2010b). 

• The use of significant/authentic problems, 
• having everyone working on the same problem, 
• requiring them to make a single choice (and defend it), and 
• enabling simultaneous reporting, 

is the start of creating a problem that will enable a more stimulating environment in which to facilitate.

시계를 잘 본다.

Ti p 2 Watch the clock

토론 단계에는 적어도 절반의 시간이 배정되어야 한다. RAT을 25분간 했다면, 토론은 25분간 한다. 적용 단계도 마찬가지여서 25분의 적용 연습 이후에는 25분 이상의 토론이 이어져야 한다.

Ideally, the discussion phase should be at least half the time allocated. In a 50-min class, that would be roughly 25 min for RATs (both individual and team) and 25 min for discussion. The application phases should follow the same guidelines. A 25-min application should be accompanied by a 25-min discussion phase (longer if possible).

수업 전에 촉진 단계에 대한 전략을 세운다.

Ti p 3 Strategize the process of facilitation with faculty before class

한 가지 시간 효과적 전략은 각 RAT 문제에 대해서 학생들이 문제를 푸는 동안 촉진 전략을 세우는 것이다.

One time-efficient way to implement this approach is for faculty to consider a facilitation strategy for each RAT question while students are working on the questions.

여러가지 상황이 있다. 모든 팀이 정답을 잘 맞췄을 경우 vs 모든 팀이 정답을 잘 맞췄지만 학습 포이느가 있는 경우 vs 교수자가 학생들이 과연 옳게 답을 맞춘건지 확인하고 싶은 경우 등등

For example, if all teams answer a particular question correctly, the facilitator may choose not to have an in-depth facilitated discussion as there may be no further learning points to be covered. Conversely, if all teams answer the question correctly but there are critical learning points, or faculty want to be sure the teams derived the correct answer for the right reason, such a question may benefit froma facilitated discussion.

As the role of the faculty during the facilitation phase is to ‘‘facilitate’’ the learning and elicit information from the students, it is critical to remain neutral and non-judgmental with the discussion as it develops. During the learner debate phase of the discussions, any sign of approval or disapproval of a comment or response will shut down the discussion immediately.

종종 교수자는 학생이 틀린 답을 말하거나 매우 훌륭한 답을 말하면 의견을 숨기기가 쉽지 않다. 이런 것을 최소화하는 한 가지 방법은 스스로를 촉진자로서 규정하고, '내용 전문가'와는 다른 역할로서 인식하는 것이다.

It is often very difficult for a faculty member to hide their opinion when a given response is factually incorrect or when it is exceptionally brilliant. One way to minimize this might be to identify one faculty as the facilitator and a different one as the ‘‘content’’ expert.

정리 시간을 마련하라

Ti p 6 Provide time for closure

촉진자가 기억해야 할 가장 중요한 것 중하나는 마지막에 정리 시간을 가지는 것이다. 각 문제를 풀고 난 이후에 매번 정리 시간을 가지면 시간 관리가 어렵다. 그러나 학생이 훌륭한 대답을 했을 때나 잘못된 주장을 정정한 학생을 강조해 주는 것은 만족과 명료함을 더해줌과 동시에 시간이 많이 들지도 않는다. 그러나 여전히 개념적으로 어려운 내용에 대해서는 세션이 종료할 때에 공식적으로 정리해주는 것이 중요하며, 이는 학생들이 서로의 지식을 완전히 신뢰하지 못하고, 다른 전문가나 교수로부터 듣고 싶어하기 때문이다. 따라서 어려운 개념에 대해서 - 학생들이 토론중이 아니라 - 수업이 끝나갈 때 정리를 해 주는 것은 학생들이 TBL이 가치있게 느끼게 하면서 중요한 'take-home information'을 가져간다고 느끼게 해준다.

One of the most important things that a facilitator should remember to do is provide time for closure at the end of the session. Providing closure after each question makes it difficult to manage time. However, highlighting a student’s excellent response or one who corrects an argument that was inaccurate can go a long way to bring satisfaction and clarity to the learning in the classroomand is not time intensive. Yet, it is still important to bring formal closure to conceptually difficult material at the end of a session as students often do not explicitly trust each other’s knowledge-base and prefer to hear from an expert faculty member or facilitator. Thus, adding closure to difficult concepts after but not during student discussions will assist in ensuring that students feel that the TBL process was valuable and that they learned the important ‘‘take-home’’ information.

Enhancing active engagement of learners

학생들의 참여를 높이기 위한 몇 가지 권고들이 있다.

There are several general suggestions to achieve classroom engagement. 

• First, be open and transparent about the intention and process of asking questions. 
• Second, create a safe environment where students can answer incorrectly without fear of ridicule or recrimination. 
• Third, consider using a randomization process (random team and random members within the team) to decide who to call upon. That way, students will not feel ‘‘picked’’ on.

학생들이 답을 할 때까지 기다린다.

Ti p 7 Wait for students to respond to questions

학생에게 답을 요구할 때에 촉진자는 자신이 충분하다고 생각한 것보다 더 긴 시간을 학생에게 줘야 한다. 종종 문제를 받은 이후의 침묵은 혼란 때문이 아니라 대답을 구성하기 위해 생각하는 시간이 필요해서이다. 팀 동료와 논의를 해서 그들이 그러한 답을 도출한 과정의 이유가 무엇인지 생각해내야 한다. 30초 정도의 시간을 주는 것이 필요하다. 학생들이 환경이 안전하다고 느낄 때 더 활발히 참여할 것이다. "dwell-time"은 그래서 필요하다.

Thus, when calling on students to respond, the facilitator is encouraged to give more time than he/she feels is necessary. Oftentimes, the silence following a question is not due to confusion over what was asked, but due to time they need to think about the way they wish to phrase their response. Other times, it is necessary for the student to consult his or her team mates as a reminder of why they answered something the way they did. Allowing up to 30s may be necessary and expected. If students feel that the environment is safe and tolerant, then they will engage more actively. Allowing for enough ‘‘dwell-time’’ after each student is called on should help in this regard.

중립적, 개방형 질문을 사용하라

Ti p 8 Ask neutral and open-ended questions

촉진자가 도입해야 하는 최고의 것 중 하나는 개방형 질문을 특정 학생에게 던져서 교실원들이 비판/분석/정당화/설명을 하게 해야하는 것이다. 예/아니오로 응답 가능한 질문은 추가적 토론을 불러올 수 없다.

One of the best practices a facilitator should adopt is to ask an open-ended question to a specific person in the classroomthat forces them to critique, analyze, justify, and explain their choice of answer (Silberman & Auerbach 2011). Questions that allow for a yes or no response will generally cease any further discussion.

학생들은 대답을 하는 중에 이리저리 왔다갔다 할 수 있다. 자신감 있게 시작했다가 기어들어가는 목소리로 끝내곤 한다. 학생이 했던 말을 다시 정리해서 말해줌으로서 촉진자는 학습자의 참여를 높이고 다음의 목적을 달성할 수 있다.

Students also frequently display ‘‘drift’’, a process where they start reporting in a confident and audible fashion, but end in a barely audible and less confident tone. By summarizing and restating what was said by the student, a facilitator can keep learners engaged and ensure that everyone hears and that 

• (1) unclear information is clarified, 
• (2) overly complex information presented is simplified, 
• (3) incorrect information is stated (non-judgmentally) to elicit debate, and 
• (4) principles can be repeated for best learning and retention.

촉진자가 rephrase해주는 것은 중요하지만, 정답을 은근슬쩍 '흘림'으로써 토론을 종결시키지 말아야 한다.

It is important to note that although the facilitator is repeating or rephrasing content for clarity often, during the facilitation process he or she is not ending discussion by ‘‘leaking’’ the correct answer or slipping into lecture mode and removing the students from the discussion.

교실 내 학생 전문가를 찾아라

Ti p 10 Find the ‘‘student expert’’ in the room

교실에서 학생 전문가를 찾기 어려울 수 있다. 좋은 방법 중 하나는 다음과 같은 탐색질문을 던지는 것이다.

It is often difficult to find the student expert in the classroom as students can be unsure of themselves and may not trust their colleagues either. One of the best ways to achieve this is to ask probing questions such as ‘

• ‘What evidence supports this?’’ or 
• ‘‘Can anyone assist us to resolve this issue?’’

학생들간의 불확실성이나 의견불일치를 해소해주라

Ti p 11 Ensure any lingering uncertainties or disagreements are addressed

학생들은 종종 자신들이 다른 팀원이 보기에 뭘 잘 모르는 것으로 비춰질까봐 걱정한다.

Students will often report what they feel pressured by the team to report to avoid looking unknowledgeable even if they do not agree with their own team’s decision. 

따라서 촉진자는 누군가 특정 의견에 대해 찬성하거나 반대하는 의견이 있는가를 확인하는 것이 중요하다. 강력한 반대의견이나 불확실성은 학습을 더욱 유발하는데, 이는 서로 동의하지 않는 상황에서 토론이 더 강렬해지고 열정적이 되기 때문이다.

It is important for facilitators to ask if there is someone in the classroom who agrees or disagrees with what was just reported and to do this often. It is those strong disagreements or uncertainties that produce the most learning as discussions tend to be more robust and passionate when people disagree.

각 학습자에게 책임을 지게 하라

Ti p 12 Hold each individual learner accountable

각 팀원이 언제든 일어나서 팀의 의견을 지지할 수 있어야 하는 환경을 만들어서 개인과 팀의 책임을 높일 수 있다. 개개인 수준에서 학생들은 준비가 되어있어야 한다고 생각할 것이며, 팀 수준에서 다른 팀원들이 확실히 의견을 대표할 수 있게 도와줄 것이다. 팀별로 발표자를 지정하는 것은 가급적 피해야 한다. 또한 학생들은 비록 개개인의 선택은 다를 수 있지만 팀의 선택을 방어하고 설명할 수 있어야 한다는 것을 지속적으로 인식해야 한다.

By creating an environment where each student knows they could be called upon at any time to respond or defend a team’s answer, you further ensure individual student and team accountability. As individuals, students will realize they must be prepared. As a team, they will try to make sure their team-mate represents the team well. It is advisable to avoid the assignment of a team spokesperson whenever possible and to remind students often that they are responsible for their team’s responses and choices. In addition, students must be remindedconstantly that although their individual choices may vary,they should be prepared to defend their team’s decisions andexplain their decision making processes to the classroom.

최대한 여러 학생들이 참여하게 한다.

It is also important to get participation from as many different individuals as possible and to avoid picking on the same vocal individuals repetitively.

촉진자는 90:10 원칙을 따른다.

A universal role of a facilitator is to observe the 90:10 rule – listen 90% of the time and talk 10% of the time (Silberman & Auerbach 2011). We consider the principle of listening more than you talk a sign of an effectively facilitated session.

TBL에서의 촉진 기술중 많은 부분은 배울 수 있지만, 어떤 부분은 "예술"의 영역이기도 하다.

Much of facilitation in the TBL classroom is a strategy and can be learned. These tips can play a role in this process. However, it is clear that there is some ‘‘art’’ to the practice of being a good facilitator. This art is hard to teach. Experience and practice is the best way to learn the ‘‘art of facilitation’’.

Twelve tips for facilitating team-based learning.

포격 속의 프로페셔널리즘: 갈등, 전쟁, 그리고 전염병

Professionalism under fire: Conflict, war and epidemics

MICHELLE MCLEAN1, VIKRAM JHA2 & JOHN SANDARS3

군복을 입고있든 아니든, 정권의 탄압이 있든 없든, 관리의료기관의 수문장 역할이든 아니든, 의사는 환자의 마지막 보루이다. 이 역할을 저버리는 것은 의학의 본분 - 지식을 사람을 돕고, 낫게 하고, 돌보는 것 - 을 저버리는 것이다.

Whether in a military uniform or not, whether a bureaucrat in an oppressive regime, whether a gatekeeper in a managed care organization, the doctor is the patient’s last safeguard. To abandon that role is to defect from what medicine is about: the use of knowledge to help, heal, cure, and care for persons. (Pellegrino & Thomasma 2000, p. 270)

의학에서 프로페셔널리즘은 다음과 같이 정의되어 왔으며 그리고 이는 의학과 사회 사이에 맺어진 사회적 계약이다.

In medicine, professionalism has been defined as ‘‘a set of values, behaviors, and relationships that underpin the trust that the public has in doctors’’ (Royal College of Physicians 2005) and is the basis of a social contract between medicine and society (Cruess & Cruess 2014). 

오늘의 의학전문직업성을 규정한 것은 Swick의 professional competencies를 기반으로 하고 있다. Sox에 따르면 '전문직업성'이라는 단어는 현대 의사에게 특별한 의미를 지닌다. 이 단어는 존경하는 모든 동료에 대한, 그리고 고군분투하는 자신에 대한 것을 모두에 대한 것이다.

Today’s medical profession- alism codes such as the 2001 American Medical Association Principles of Medical Ethics and the 2002 Professional Charter have been framed around Swick’s (2000) professional competencies (Table 1). For Sox (2007), ‘‘the word profes- sionalism has a particular meaning to contemporary phys- icians. It connotes everything that we admire in our colleagues and strive for in ourselves’’ (p. 1532).

Conflict and war

홀로코스트의 잔혹성은 아마도 인간에 대한 범죄의 가장 극명한 사례일 것이다. 뉘른베르그 코드와 같이 이런 일이 다시는 일어나서는 안된다는 전 세계적인 합의가 있었지만, 다시 일어나고 말았다. IMAP TF 보고서와 US SSCI에서는 부시행정부가 테러와의 전쟁을 치르는 동안 CIA에 의해 자행된 고문과 비인간적 행위를 인정했다. IMAP 보고서에서는 구체적으로 기술했다. 

The atrocities of the Holocaust are probably the most explicit examples of crimes against humanity (Pellegrino & Thomasma 2000; Geiderman 2002a,b; Chelouche 2005, 2008). Despite universal acceptance (e.g. Geneva Conventions, Nuremburg Code) that such abuse and dehumanization should never be allowed to happen again, it has. Both the Institute on Medicine as a Profession (IMAP) Task Force Report (2013) and the United States (US) Senate Select Committee on Intelligence (2014) have made public the torture and inhumane treatment of detainees at the hands of the US Military and the Central Intelligence Agency (CIA) during the Bush regime’s War on Terror which began after the events of 9/11. The 2013 IMAP report specifically described how military medical personnel were involved in monitoring oxygen saturation during water- boarding, watched for edema in detainees forced to stand in stress positions, shared information from prisoners’ health records with interrogators and force-fed prisoners (Okie 2005; Clark 2006; Miles 2007, 2013; IMAP 2013; Kimball & Soldz 2014), as well as failing to document evidence of torture in many instances (Iacopino & Xenakis 2011).

911사건은 새로운 종류의 전쟁을 이끌어낸 계기가 되었다. 군의사가 개입하기 시작한 것이다.

The events of the 11 September 2001 led to ‘‘a new kind of war’’ (War on Terror), one in which the ‘‘long-accepted norm barring military clinicians from being involved in coercive interrogations of prisoners and in administering non-thera- peutic drugs to soldiers’’ (Miles 2013, p. 117) was set aside. So began a period of obtaining information at any cost, a time in which military medical personnel participated in activities which ‘‘represent a dramatic departure from the conventional medical ethics, which are anchored in the ‘‘do no harm’’ principle’’ (Kimball & Soldz 2014, p. 1) and which violated widely accepted ethical standards set out in the United Nations Principles of Medical Ethics, the Geneva Conventions and the Declarations of Tokyo and Malta (Clark 2006; Miles 2007; IMAP 2013).

Clark의 질문은 주목할 만 하다. "잘 훈련받은 의료인이 이러한 행위에 동참하는 것, 더 나아가 여기에 대해 조용히 있는 것은 우리의 의학교육 시스템이 문제가 있음을 보여주는 것일까? 이 부적절한 프로페셔널리즘적 행위와 주변 맥락을 함께 살펴본다면, 이 행위 중 일부는 미국 정부가 WoT 를 치르는 동안에 자행된 것임을 눈여겨봐야한다."

In the light of this discussion, Clark’s (2006) question becomes pertinent: Is there something fundamentally wrong with our medical education system that allows well-trained medical personnel to become actively involved in abuses, or, even worse, remain silent? To place these reported ‘‘lapses’’ in professionalism into context, it is important to note some of the actions taken by the US government and military during the War on Terror (IMAP 2013):

따라서, WoT동안 많은 군 의사와 심리학자들은 법적 구속력이 있는 지침에 따라 행동했고, 이것을 따르지 않는 것이 위법이 될 상황이었다.

Thus, during the War on Terror, many military physicians and psychologists acted under legally binding instructions, with disobedience carrying the threat of misconduct and possible dismissal (Physicians for Human Rights 2014).

감염질환과 유행병

Infectious disease and epidemics

역사적으로 유행병에 대한 의사들의 반응은 여러 갈래였다. 흑사병 시기에 그 환자들을 보는 것은 개인적 선택이었지만, 1847년 이후 여러 규정이 등장하였다. 1912년에는 그러한 환자를 돌보는 것이 대중의 일반적인 기대였고, 이것으로 인해서 1920년과 1940년 사이에는 많은 의사들이 결핵에 걸리거나 사망하기도 했다. 그러나 1950년대가 되어서는 유행병이 크게 줄어들면서 1977년에는 전염병과 관련된 조항이 삭제되었다.

Historically, physicians’ responses during epidemics have been mixed. For example, during the plague outbreaks of Europe, some stayed with their patients, often succumbing to the disease. Others fled, abandoning their patients (Huber & Wynia 2004). At that time, treating such patients was viewed largely a matter of personal choice, a charitable act or a religious obligation until the founding of 

• the American Medical Association (AMA) in 1847 when explicit professional ethical standards around treating infected patients were formalized. The 1847 Code specifically stated ‘‘when pestilence prevails, it is [physicians’] duty to face the danger, and to continue their labors for the alleviation of suffering, even at the jeopardy of their own lives’’. 
• This was strengthened in 1912 (Principles of Medical Ethics) with ‘‘When an epidemic prevails, a physician must continue his labors for the alleviation of suffering people, without regard for risk of his own health or financial return’’ (Baker et al. 1999). At that time, it became a public expectation that physicians treat the sick which probably accounted for many physicians contracting and even succumbing to tuber- culosis between 1920 and 1940. 
• By the 1950s, however, the risk of epidemics had fallen dramatically and, in 1977, the principle of care relating to epidemics was removed from the Principles of Medical Ethics (Huber & Wynia 2004).

최근의 Ebola, 조류독감, 사스 등의 사태는 의료 전문직업성을 더 살펴볼 수 있는 계기였다. 어떤 사람은 이타적으로, 어떤 사람은 보다 자신의 안전을 중심으로 행동했다. 그리고 이것을 바라보는 관점도 자신에 대한 보호라는 견해부터 책무를 이행하지 않았다는 것까지 다양했다.

Recent outbreaks of Ebola, avian flu and SARS (severe acute respiratory syndrome) have provided opportunities to further explore medical professionalism in the context of emerging health threats. While altruism led to many individ- uals risking their lives to serve affected patients, the behavior of others could be deemed to be more self-serving: Compensation requests, failure to report for work and refusal to put oneself at risk (Straus et al. 2004; Reid 2005; Shiao et al. 2007; Seale et al. 2009; Kinsman 2012; Silva 2014; Yakubu et al. 2014). Perceptions of these actions have ranged from self- preservation to abandonment of duty (Reid 2005; Kinsman 2012).

Understanding what underpins behavior may help to explain why health care professionals chose to behave differently when faced with moral challenges.

모든 행동은 개인적, 사회적, 환경적 복잡한 관계의 영향을 받는다. 따라서 의료 전문직업성에 대한 개인주의적 관점은 의사들이 전문직으로서 어떻게 행동하는지를 완전히 설명해주지 못하며, 이는 특히 전문직으로서의 가치와 신념이 도전받는 상황에서 더욱 그러하다. 다음과 같은 다양한 관점이 있다.

Any behavior is therefore a complex relationship involving the individual and social influences, including environmental factors (e.g. threat, peer pressure, law). An individualistic perspective of medical professionalismtherefore does not fully explain how physicians develop and act as professionals, especially when their fundamental professional values and beliefs are challenged (Martimianakis et al. 2009).

• For Ginsburg and colleagues (2000), context is important in influencing individual factors in this model. In terms of military medical personnel, dual loyalty, the need to balance the medical needs of patients in the face of a duty to an employer, has been used to explain why physicians have been seen to act ‘‘unprofessionally’’ in challenging circum- stances (Sidel & Levy 2003; Clark 2006; Snow 2007; Miles 2013; Kimball & Soldz 2014; Solberg 2014).

• As Powell (2005) has pointed out, the ethos of an organization or a cause can be internalized, prompting actions which the individual would not normally perform. Such acts might include medical personal being aware of (and not reporting) or participating in physical or psychological abuse or torture.

• Gross’ (2006) provocative debate on nationalism vs. morality in challenging circumstances such as conflict considers the rights of the individual (the prisoner) and ‘‘the greater good’’ (national security). 
• In his view, a physician’s duty, like any citizen, is to consider the humanitarian issues involved and question national directives. 
• He argues, however, that there may be times, in the interest of national security, that a physician is required to certify that a detainee is medically fit to undergo interrogation because the benefit to the nation outweighs the needs of the individual. 
• TBP에 따르자면 이런 상황에서는 주관적인 규범이 더 강력한 동기가 된다.
  In terms of the TPB, the subjective norm (i.e. social pressure to respond) would thus be a powerful motivator to comply.

전염병이나 공공보건에 관한 이슈에 대해서 이해할 때 어떤 연구자들은 어떻게 개개인이 반응하며, 무엇이 그러한 행동의 기저에 있는가에 대한 통찰을 제시했다. 

In terms of understanding responses to epidemics and public health issues, several authors have provided useful insight into how individuals respond and what might underpin their actions (Straus et al. 2004; Reid 2005; Qureshi et al. 2005; Seale et al. 2009; Connor 2013, 2014; Silva 2014). Of particular relevance in this context are Reid’s (2005) debate on risk and the duty to care and Connor’s (2014) TPB modeling on the intention of health care workers to respond. 

• Reid에 따르면 사회는 적절한 보건의료 시설을 갖추고 예방적 규정을 마련하는 것과 같이 동등한 책임을 갖는다.
  Reid’s (2005) discussion, sparked by the SARS epidemic revolves around the risk health care workers faced and the unrealistic social expectation to treat, irrespective of their personal well-being. For Reid (2005), unrealistically, ‘‘the social contract forming the professions leaves us with no one but the licensed healthcare professionals to turn to in an emergency’’ (p. 353) and ‘‘posing the issue of duty of care solely in terms of an obligation to others in conflict with self-interest fails to capture the real moral dilemmas faced by healthcare workers in an infectious epidemic’’ (p. 358). In Reid’s (2005) opinion, it should be incumbent upon society to equally share in the responsibility during such episodes by, for example, ensuring appropriate health care infrastructure and by having appropriate precautionary regulations.

• 공공적 응급상황에 대응하는 것은 perceived behavioral control > subjective norm > outcomes belief 순서로 영향을 받는다.
  Connor (2013, 2014) found that the intention to respond to public health emergencies is influenced directly and foremost by perceived behavioral control, followed by the subjective norm, and, to a lesser extent, by outcomes beliefs. The decision to respond to a disaster is thus a complex balance between 
• personal (e.g. knowledge, skills, duty to patients vs. loved ones), 
• contextual and environmental (e.g. natural disaster vs. biological or chemical) and 
• social (e.g. response role) factors (Connor 2013, p. 5). 

• 확실한 가이드라인 없이는 의료인력은 도덕적 딜레마에 빠지게 된다. 여러 상황이 종합되면 '양심'의 값이 비싸진다.
  Yakubu and colleagues’ (2014) article on the ethical obligations during the recent Nigerian Ebola outbreak identifies just this in the face of no clear guidelines: ‘‘In the absence of clear guidelines, healthcare workers face a moral dilemma. Their conscience urges themto treat all patients, but convergence of...
• failed health system factors, 
• the danger to life, 
• emotional considerations like danger posed to family and friends, and 
• the absence of commensurate compensation for engaging in high risk service can make following one’s conscience costly’’ (p. 1).

Bryan은 기초-전문직업성과, 상위-전문직업성을 구분하였다.

Bryan (2003) explains some health care professionals risking their own lives for the greater good in terms of two types of professionalism, which he calls basic and higher professionalism. 

• 모든 의료인은 기초-전문직업성 All health care professionals should demonstrate basic professionalism. 
• 소명과 같은 상위-전문직업성 Higher professionalism, however, becomes important in challenging situations. Higher professionalismis a calling, often with little or no prospect of reimbursement, is virtue-based and usually involves substantial personal risk. 
• 에볼라에 대응한 의사와 같은 사례
  Time Magazine’s recent Person of the Year issue, which recognizes the heroic work of some of those involved in dealing with the recent Ebola outbreak in Liberia, exemplifies this higher professionalism: ‘‘Doctors who wouldn’t quit even as their colleagues fell ill and died; nurses comforting patients while standing in slurries of mud, vomit and feces’’ (http:// time.com/time-person-of-the-year-ebola-fighters/). 
• 학생을 선발할 때 이러한 상위-전문직업성을 보유한 개인들이 비록 최상위 성적이 아니더라도 입학할 수 있게 해야 함.
  As many individuals with such a calling will apply to study medicine and other health professions, the challenge is to ensure that our admission criteria include such individuals, even if they are not the highest academic achievers (Box 1).

이러한 상황에 직면한 모든 의사가 근본적 도덕 원칙에 반하여 행동하는 것은 아니다. 사회학적 관점이 유용한 통찰을 제공한다.

Not all doctors faced with challenging situations will, however, act against their fundamental moral principles (Perl 1948; Leyton & Locke 1998). A sociological perspective provides a useful insight, highlighting the dynamic relationship between individual agency (freedom to choose from a range of valued options and outcomes) and the social structures within which the individual is working and living (Archer 1995). 

• The development and maintenance of individual agency is complex but depends on a clear moral purpose and a well-developed professional identity (Korsgaard 2009). We believe that medical and health professions education has a responsibility to assist individuals to develop a strong moral purpose, with well-constructed personal and professional identities and to explore how these may be challenged. 
• This can be done by selective prompts for discussion (Lifton 2000;Hsin & Mercer 2004) and by fostering a constant reflective approach to practice thereby creating an increased awareness of the influence of social structures on one’s behavior(Archer 2003). 

학생의 성찰 능력을 키워줘야 한다. 그러한 상황이라면 자신의 신념에 의해, 그리고 행동의 결과에 기반하여 어떻게 행동했을지 생각해봐야 한다.

By developing students’ reflective skills, medical and health professions education can assist students (and later, as professionals) maintain their moral purpose in difficult situations. Students (and health professionals) need to reflect on how they might behave during challenging times, based on their own beliefs about their behavior, as well as the outcomes of the behavior (i.e. their behavioral beliefs). 

TPB를 활용한 시나리오 제공

Using the TPB,students can be provided with scenarios in which personal risk needs to be evaluated, taking into consideration the possible variables, opinions e.g. and 

• outcomes (e.g. personal benefit or loss),
• involvement of colleagues (i.e. normative beliefs), 
• incentives (e.g. financial or social gains) and 
• barriers (e.g. unsafe working conditions). 

We also need to make our graduates aware of the need to continue to develop the skills required to deal with challenging situations. This is particularly important for those joining the armed forces or who volunteer during civilian crises. Although ethical guidelines have emerged from the experiences of medical personnel during the War on Terror (e.g. 2012 British Medical Association toolkit for ethical decision-making for doctors in the armed forces), understanding how humans behave in a range of challenging contexts and examining how one might respond if confronted with similar scenarios, will contribute to developing the skill of reflection as an tool to regulate our graduates’ actions when under pressure and to ensure the maintenance of a True North on their moral compass. 

Professionalism under fire: Conflict, war and epidemics.