50년의 의학교육연구 : 이주의 물결(waves of migration) (2) - 상식의 실패, 그리고 융합의 성공

(출처 : http://berlinstirredup.wordpress.com/2012/02/10/opposites-attract/)

상식의 실패, 그리고 융합의 성공

THE FAILURE OF ‘COMMON SENSE’ AND THE SUCCESS OF MULTIPLE DISCIPLINES

학습

Learning

의학교육의 많은 연구가 학습에 대한 상식적 개념에서 출발했다.

Much research in medical education is driven by commonsense notions about the nature of learning: 

(i) learners have different needs, motivations, aptitudes and abilities; instruction should accommodate these; 

(ii) different instructional methods and formats lead to different outcomes, and 

(iii) the more the instructional method encourages activities that are closer to those carried out in the real world, the better the learning.

실패(The failures)

불행하게도, 많은 연구에서 이러한 상식은 하나도 증명되지 못했다. 학습방법에 맞춘 교육이 더 나은 결과를 가져오지도 않았고, 다양한 교육방식이 다른 결과를 가져올 것이라는 생각도 systematic review에 의해 반박당하고 있다.

Unfortunately, despite multiple studies, none of these commonsense axioms finds much support in the literature. Matching learning styles has never been demonstrated to lead to superior outcomes, in either general8 or medical9,10 education. The idea that different instructional formats lead to consistently different outcomes has been challenged by several systematic reviews of e-learning11 and PBL.4

성공(The successes)

반대로, 인지심리학에서 유래한 이론들은 예측가능하고 일관적성있게 도움이 되는 교육 전략을 제공했다. 

Conversely, theories derived from cognitive psychology point to some general instructional strategies that lead to predictable and consistent benefits.12 

Problem-based learning curricula that are directed at the activation of prior knowledge lead to better transfer.13 

The use of multiple examples and commonsense analogies that direct students to the deep conceptual structure of the problem results in significant gains in transfer.14 

Mixed practice, in which examples from different categories are mixed together, and distributed learning, in which learning is spread over several occasions, are both effective strategies directly related to cognitive theories of learning.15,16 

Cognitive load theory17 provides a strong theoretical basis for effective instructional design, is generally directed to simpler presentations and has consistent and strong effects.

임상 문제해결 기술과 임상 추론

Clinical problem-solving skills and clinical reasoning

실패(The failure)

아마 가장 좋은 사례는 McGuire의 연구일 것이다.

Perhaps the best example of a failure of common sense derives from McGuire’s own work.2

많은 학교들이 급진적으로 PBL과 같은 접근법을 도입했다.

New medical schools pioneered radical approaches such as PBL

문제해결능력을 위한 것이었고, 전문가와 초심자의 차이는 전문가는 뛰어난 문제해결 능력을 가지고 있다는 근거로부터 출발한 것이다.

toward measures of ‘problem-solving skills’. The term had common appeal; it was proposed that the differences between experts and novices derived from the fact that experts had good problem-solving skills and novices had still to acquire them.

이 분야에서 가장 발전한 것은 McGuire와 Babbott의 PMP이다.

The best-developed of these was McGuire and Babbott’s patient management problem (PMP),18

그러나 PMP에 대한 psychometric연구와 임상문제해결에 관한 기초연구 모두 불분명한 결과만을 보였다. 

However, both psychometric study of PMPs and fundamental research around ‘clinical problem solving’ revealed a disquieting finding. However, it was measured, the correlation across problems was 0.1–0.3.19,20

성공(The success)

Content Specificity에 관한 일관된 연구결과는 일반적 기술(general skill)은 손실되기 쉽고, 지식이 전문가에게 있어 핵심적인 것이라는 점이었다. 그러나 이것은 지식은 전문성과 관련이 없고, 5년마다 근본적으로 바뀐다는 인식이 널리 퍼져있던 시절에는 직관에 반하는 결론이었다.

The consistent finding of content specificity led inexorably to the conclusion that general skills are evanescent and that knowledge plays a central role in expertise; this represented a counter-intuitive result at a time when proclamations that knowledge was irrelevant and fundamentally changed every 5 years were rife.

이는 약간의 패러다임의 변화를 가져와서, 지식의 이론을 바탕으로 한 연구의 새로운 세대의 시작이 되었다.

This led to a small paradigm shift within the domain and the birth of a new generation of research strongly driven by theories of knowledge

비록 각각의 연구는 임상추론에 관해서 조금씩만 기여할 뿐이지만, 그것들이 합해져서 더 풍부하고, 더 강력한 설명을 제공한다.

Although each theory provides at best only a partial representation of the phenomenon of clinical reasoning, the collective provides a far richer, and more powerful, explanation of the phenomenon that is frequently at variance with common sense.

평가

Assessment

실패(The failure)

학습에 대한 상식이 그랬던 것처럼, 평가에 대한 것도 그럴듯하지만 틀린 것들이 많았다. 첫 번째는 평가의 포멧이 다르면 다른 능력을 평가할 것이라는 상식이었다.

Parallel to commonsense views of learning, assessment research has been driven by some plausible but incorrect views about assessment. First is that different assessment formats necessarily assess different abilities

두 번째 가정은 평가 방식이 실제상황과 비슷할수록, 더 나은 평가라는 것이다.

A second assumption is that the closer the assessment resembles reality (and the higher up the Miller31 pyramid it goes), the better the assessment.

'의학적 역량에 대한 평가를 디자인 할 때는 얼마나 현실과 가까운가(authenticity)가 우선되어야 한다. 이는, 평가를 하는 상황이 실제로 그 역량이 활용되는 환경과 비슷해야 한다는 것이다.'

‘Authenticity should have high priority when programmes for the assessment of medical competence are being designed. This means that the situations in which a candidate’s competence is assessed should resemble the situation in which the competence will actually have to be used.’32

그러나, 아쉽게도 이런 가설은 연구에 의해 뒷받침되지 못했다.

Regrettably, again, the research evidence does not support either assumption

성공(The success)

일찍부터 의학교육은 최신의 psychometric 방법을 도입하기 시작했다. 이러한 변화는 미국과 캐나다의 면허기관에서 주로 도입되었다. 그 결과는 summative assessment(총괄평가)의 방법을 바꾸어놓았고, 현재 사용되는 generalizability theory와 IRT를 분석에 사용하여 의학교육의 방법론이 보통교육(general education) 방법론의 엄격함을 능가할 정도였다.

Quite early in its history, medical education began to adopt state of-the-art psychometric methods. These changes were primarily driven by the national licensing bodies in the USA and Canada. The consequence was sweeping changes in approaches to summative assessment, with the adoption of contemporary methods like generalisability theory and IRT for analysis, to the extent that medical education overtook general education in its methodological rigour.37

시험의 효율성이 높아졌을 뿐만 아니라, 더 높은 예측타당도도 가진다는 것이 증명되었다.

Not only has the efficiency of testing been improved by the application of methods like IRT, but the latter has also been accompanied by consistent evidence of high predictive validity.34,38,39

학제간 융합의 유용성

THE USEFULNESS OF MULTIPLE DISCIPLINES

위의 예들이 보여주는 바와 같이 MER의 강점은, 마치 영어와 같이, 특별한 노력을 기울이지 않고도 다양한 학문의 언어를 흡수할 수 있다는 것이다.

As these examples illustrate, one great strength of MER derives from its ability, like the English language, to effortlessly absorb other disciplinary languages

어떻게 그럴 수 있을까?

What makes this possible? 

첫 번째로, 의학교육은 다양한 관점을 증명할 수 있는 바탕이 되며, 관심의 영역이 수술실에서의 전문가간 의사소통부터, 영상의학에서의 패턴 인식과 인지까지 다양하다.

Firstly, medical education is a rich proving ground for different perspectives, whether the issue of concern relates to factors in interprofessional communication in the operating theatre or a study of pattern recognition and perception in radiology

두 번째로, 더 중요한 것은, Buffalo에서 시작할 때부터 교육환경을 더 풍요롭게 만들고 싶어하는 다양한 보건의료인력을 끌어당겼다는 것이다.

Secondly, and most importantly, from its humble origins in Buffalo, MER has always attracted a coterie of dedicated health professionals with an interest in enriching the teaching environment.

마지막으로, 가장 중요한 것은 MER이 지속적으로 다양한 분야의 학자들의 마음을 끌고 있다는 점이다.

Finally and, in my view, most critically, MER has attracted and continues to attract scholars from multiple disciplines in the behavioural and social sciences. 

실제로, 교육 과학을 흥미롭게 만드는 것은 상식에 의해서 증명되지 않는 것들이 있고, 오히려 직관에 반하기도 한다는 점이다.

Indeed, what makes education science, like all science, such an exhilarating voyage of discovery is that findings so often turn out to be not predictable by common sense, but instead appear to be counter-intuitive,

이 리뷰에서 말하고자 하는 두 번째 것은, 최근 몇몇 commentaries에서 언급된 허무주의적인 태도에 대한 것이다. 교육은 너무 복잡해서 잘 정의되지 않고, 일반화하려는 시도는 빈번히 실패한다는 주장은, 내가 인용한 많은 사례들은 현실적인 문제들과 환경에서 성공적이었을 뿐만 아니라 그 효과도 컸다.

A second insight to emerge from this review refers to the fact that the examples I have chosen provide, I believe, a strong antidote to somewhat nihilistic recent commentaries,6,41 the thesis of which appears to be that education is so complex and ill defined that any attempt to find generalisable truths is bound to fail. Many of the studies I have cited on the ‘success’ side are based on realistic tasks and environments – such as diagnosis of electrocardiograms or learning from resident half-days – yet show large effects.

의학교육연구의 미래

THE FUTURE OF MER

‘Rigorous and relevant research requires a combination of well-trained educationalists and researchers with good practical knowledge of medicine and teaching. One conclusion from all of these is that a close collaboration between doctors and educationalists is indispensable for good medical education and development of better education. Any monodisciplinary endeavour will lead to a suboptimal result.’32

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Med Educ. 2011 Aug;45(8):785-91. doi: 10.1111/j.1365-2923.2010.03921.x.

Fifty years of medical education research: waves of migration.

Norman G.

Source

Department of Clinical Epidemiology and Biostatistics, Faculty of Health Sciences, McMaster University, 1200 Main Street West, Hamilton, Ontario, Canada. norman@mcmaster.ca

Abstract

CONTEXT:

Medical education research has been an academic pursuit for over 50 years, tracing its roots back to the Office of Medical Education at the State University of New York at Buffalo, New York, with George Miller. As the field has matured, the nature of the questions posed and the disciplinary bases of its practitioners have evolved.

METHODS:

I identify three chronological 'generations' of academics who have contributed to the field, at intervals of roughly 10-15 years.

RESULTS:

Members of the first generation came from diverse and unrelated academic backgrounds and essentially learned their craft on the job. A second generation, emerging in the 1980s and 1990s, consisted of individuals with PhD-level training in relevant fields such as psychology, psychometrics and sociology, who actively chose a career in health sciences education, often during graduate work. These individuals brought a strong disciplinary orientation to their research. Finally, the proliferation of graduate programmes in medical education means that we are now seeing the evolution of a new type of academic, often a health professional, whose only discipline is medical education.

CONCLUSIONS:

I propose that we should strike a balance between seeking to create a separate specialty of medical education and continuing to actively recruit from other academic disciplines. I believe that the strong disciplinary roots of these individuals are a critical element in the continuing growth and progress of medical education research.

© Blackwell Publishing Ltd 2011.

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• Is a political approach to academic leadership the right move to make? [Med Educ. 2011]