베를린은 학부의학교육과정을 개편하기 시작했다: 개발의 역사, 원칙, 종결 돌아보기 (GMS J Med Educ. 2019)

베를린은 학부의학교육과정을 개편하기 시작했다: 개발의 역사, 원칙, 종결 돌아보기 (GMS J Med Educ. 2019)
The Berlin reformed curriculum in undergraduate medical education: a retrospective of the development history, principles, and termination 

Jutta Begenau1
Claudia Kiessling2

 

The Reformed Medical Curriculum (RMC) at Charité-Universitätsmedizin Berlin was launched in autumn 1999, while medical schools in Canada, Jutta Begenau1 Claudia Kiessling2 the United States, Scotland, the Netherlands, and Scandinavia already had adapted educational reforms in medical education many years before [1], [2].

1. 학생파업부터 베를린 의료개혁 교육과정 출범까지
1. From a student strike to the launch of the reformed medical curriculum in Berlin

다음 섹션은 초기 단계에서 개혁 운동가가 된 두 명의 전직 학생 운동가들과 세 명의 의사들에 대한 다섯 번의 인터뷰와 여러 출처에서 도출된다.

• 닥터 메드. Walter Burger, 1995년부터 2005년까지 RMC 워킹 그룹의 대표(인터뷰 파트너 1 WB) 
  
• 닥터 메드. 2001년부터 2004년까지 샤리테의 학장이자 RMC 연구 위원회(인터뷰 파트너 2 JD)의 오랜 책임자인 요아힘 듀덴하우젠. 
  
• 닥터 메드. Claudia Kiessling, RMC 워킹 그룹(인터뷰 파트너 3 CK)의 공동 설립자 및 구성원. 
  
• 의학박사 Udo Schagen, 의학 역사 연구소의 연구 부서장이자 RMC(인터뷰 파트너 4 US)의 첫 번째 지지자 중 한 명. 
  
• 의학박사 Kai Schnabel, RMC 워킹 그룹(인터뷰 파트너 5KS)의 공동 설립자이자 멤버입니다.

The following section draws from several sources and five interviews with two former student activists and three medical doctors who became reform activists at an early stage:

• Prof. Dr. med. Walter Burger, head of the RMC working group from 1995 to 2005 (interview partner 1 WB);
• Prof. Dr. med. Joachim Dudenhausen, Dean of the Charité from 2001 to 2004 and longstanding head of the RMC Study Committee (interview partner 2 JD);
• Prof. Dr. med. Claudia Kiessling, co-founder and member of the RMC working group (interview partner 3 CK);
• Dr. med. Udo Schagen, head of the research unit for Contemporary History at the Institute of History in Medicine and one of the first supporters of the RMC (interview partner 4 US); and
• Dr. med. Kai Schnabel, co-founder and member of the RMC working group (interview partner 5 KS).

RMC의 탄생은 1988/89년 가을, 학생들의 유니-머트 파업으로 특징지어진다. 이 파업은 베를린 자유대학(FUB)에서 시작되어 곧 서독 전역으로 확산되어 거의 한 학기 동안 지속되었다. 학생들은 FUB에서 현재 진행 중인 학과 및 학원의 구조조정 방안과 관련하여 학업 및 정치 참여의 부족과 그들의 학업 조건에 불만이었다. 파업 참가자들의 공통점은 대중대학에서 공부한 경험이었다[6]. 그러나 의료 교육 과정도 문제가 있었다. "공부 과정은 제 마음에 별로 학문적이지 않았습니다. 모든 주제는 강의, 실험실 과정, 세미나 및 튜토리얼에서 네 번 반복되어졌다. 게다가, 그것은 때때로 실험실 과정 소개에서 언급되었다. (…) 그것은 내가 과학 연구를 상상했던 방식이 아니었다. 자기 주도 학습은 물을 것도 없었고, 그것은 완전히 타인에 의해 지시되었다. [KS, S.10]" 학생 파업자들은 "베를린 모델"이라고 불리는 8쪽짜리 논문에서 학습 개혁에 관한 초기 아이디어를 요약하고 1988년 말 CK에서 1,000명 이상의 학생들이 참석한 전체 회의에서 통과시켰다. 그러나 개혁에는 법적 규제와 지지자들이 필요했다.
The birth of the RMC is marked by the students’ Uni-Mut strike in autumn 1988/89 [4], [5], [6], [7]. The strike started at the Free University Berlin (FUB), soon spread across the entire West Germany, and lasted nearly a full semester. Students were dissatisfied with their study conditions and lack of academic and political participation, for example with regard to the ongoing restructuring measures of departments and institutes at the FUB. What all participants in the strike had in common was the experience of studying at a mass university [6]. However, the medical curriculum was problematic as well. “The course of study was not really scholarly to my mind. Every subject was covered four times: in a lecture, in a laboratory course, in a seminar and in a tutorial. In addition, it sometimes came up in an introduction into the lab course. (…) That was not how I imagined the study of science. Self-directed learning was out of question, it was completely directed by others” [KS, S.10]. The student strikers outlined the initial ideas regarding study reforms in an eight pages long paper, called “Berlin Model” and passed it in a plenary assembly attended by more than 1,000 students in late 1988 [[8], CK]. However, reforms needed legal regulations and supporters.

1.1. 개시자, 지지자, 반대자 및 상황
1.1. Initiators, supporters, opponents, and circumstances

시작은 1988/89년 유니뮤트 파업 당시 의학교육에 불만을 표명한 학생들이었다. 파업에 이어 한 무리의 학생들이 개혁 사상에 대한 연구를 계속했고 상당한 끈기를 보였다. 이들을 하나로 묶은 것은 자기주도적, 모범적, 환자지향적, 실천지향적 학습에 중점을 둔 의료교육이 전통적인 학습과정보다 전문직 진로에 더 잘 대비할 수 있다는 믿음이었다.
The initiators were students who expressed dissatisfaction with their medical education during the Uni-Mut strike in 1988/89. Following the strike, a group of students continued to work on reform ideas and showed considerable stamina. What united them was the belief that medical education that focuses on self-directed, exemplary, patient-oriented, and practice-oriented learning would prepare them better for their professional career than the traditional course of study.

파업 후에도 계속해 온 10명의 의대생들은 운이 좋았고 설득력을 가지고 있다는 것을 증명했다. 그들은 교수진 내의 [의사 결정권자들이 그들을 지지하고 그 과정을 추진하도록 설득]하는 데 성공했다. 그들은

• 의학사 연구소의 롤프 위나우, 우도 샤겐, 에버하르트 괴벨
  
• 루돌프 비르호우 대학 병원의 Dieter Scheffner 학장과 Jaachim Dudenhausen 부학장,
  
• 소아과 의사 월터 버거,
• 이후 두 의학부가 통합되면서, 교수와 학습에 대한 강한 인식과 관심을 가지게 되된 하랄드 마우와 요아힘 두덴하우젠이라는 양 쪽의 학장 및 많은 동료 [JD, S.8].

The ten medical students who kept going after the strike were lucky and proved to possess persuasive power. They succeeded in convincing decision makers within the faculty to support them and push the process forward [WB].Those were

• Rolf Winau, Udo Schagen and Eberhard Göbel from the Institute of History of Medicine,
• Dean Dieter Scheffner and Vice Dean Joachim Dudenhausen from the University Hospital Rudolf Virchow,
• paediatrician Walter Burger,
• and later on – after the merging of two medical faculties – both Deans, namely Harald Mau and Joachim Dudenhausen, and numerous colleagues from the Charité with a strong awareness of and interest in teaching and learning [JD, S.8].

그러나 다소 개방적인 반대론자들도 있었다. 그들은 다른 많은 다른 대학 교사들처럼 "의학 교육 개혁의 필요성에 대한 이해"가 부족했다. 그들의 걱정 중 하나는 다음과 같다. 실용적인 응용과 기술에 집중함으로써, 계획된 개혁은 과학적 기반을 약화시키고 "맨발의 의사"를 배출할 것이다. 그들 중에는 자신의 "특권"을 옹호하고 [JD, S.7] 자신의 "훌륭한 강의가 그들이 제공할 수 있는 가장 의미 있는 강의"라고 믿는 교사들도 있었습니다 [JD, S.7].
However, there were also more or less open opponents. They were lacking – like many other university teachers elsewhere [9] – the “understanding of the necessity to reform medical education” [9]. One of their reservations was: by focusing on practical applications and skills, the planned reform would thus weaken the scientific foundation and produce “barefoot doctors”. Among them were also teachers who defended their “privileges” [JD, S.7] and who believed that their “wonderful lecture was the most meaningful they could provide” [JD, S.7].

FUB에 따르면, 반대자들은 주로 베를린 달렘의 전임상 부서에 있었으며 "독일에서 가장 보수적인 부서들 중 하나"로 알려져 있었다 [KS, S. 24]. 운동가 중 한 명은 "자유 대학의 믿을 수 없는 방해 행위"를 기억한다[WB, S.7].
Based at the FUB, the opponents were mainly located at preclinical departments in Berlin Dahlem and were known to be “among the most conservative ones in Germany” [KS, S. 24]. One of the activists remembers an “incredible obstructionism from the Free University” [WB, S.7].

개혁 노력은 70년대에 시작되어 80년대에 속도를 높인 교육 개혁에 대한 전국적인 토론에 의해 뒷받침되었다. 토론회는 의료교육에 필요한 변화와 관련하여 "증거 기반 전문지식이 국제적으로 발전했다"는 것과 미국, 캐나다 등에 있는 국제적으로 유명한 많은 의과대학은 이미 개혁을 시행하기 시작했다고 인정했다.
The reform efforts were supported by a nationwide debate about education reforms, which started in the seventies and picked up pace in the eighties [10], [11], [12]. The debate acknowledged that “evidence-based expertise had developed internationally” [11] regarding necessary changes in medical education and that many internationally renowned medical faculties in the United States, Canada etc. had already started to implement reforms.

저명한 개혁 지지자들은 로베르트 보쉬 재단이 설립한 무르하르트 크라이스와 카를 구스타프 카루스 재단의 회원들인 튀레 폰 우엑퀼과 한네스 파울리였다. 중요한 충동은 독일 보건부가 시행한 과학위원회(Bissenschaftsrat)[15]와 전문가위원회(Sachverständigenrat)에서 나왔다[16]. 게다가, 학생들은 마스트리히트, 해밀턴 (맥마스터), 앨버커키, 린쾨핑과 같은 유명한 개혁 대학의 전문가들에 의해 지원되었다.

Prominent reform supporters included members of the Murrhardter Kreis – founded by the Robert Bosch Foundation – and members of the Carl Gustav Carus Foundation, namely Thure von Uexküll [13] und Hannes Pauli [14]. Vital impulses came from the Science Council (Wissenschaftsrat) [15] and a Council of Experts (Sachverständigenrat) implemented by the German Ministry of Health [16]. Furthermore, students were supported by experts from well-known reform universities like Maastricht, Hamilton (McMaster), Albuquerque, and Linköping.

1.2. 시작, 위기 및 구현: 과제
1.2. Start, crisis, and implementation: challenges

본 절에서는 RMC의 개발 10년을 중점적으로 다루는데, 인터뷰에 따르면 RMC의 역사는 도전과 과제가 다른 3단계로 세분화될 수 있다.
This section will focus on ten years of developing the RMC. According to the interviews, the history of the RMC can be subdivided in three phases with different challenges and tasks.

1.2.1. 시작: 많은 것이 해결되었다.
1.2.1. Start: „Many things have been worked out“

그 출발점은 "인할츠 AG"의 "토르소"였고, 파업 중에 공부 조건을 논의하기 위해 결성된 단체였으며, 파업 후에도 그 단체를 존속시킨 10명의 학생들이었다. 그들은 "베를린 개혁 모델을 실행하기 위한 계획을 추진했다" [17], 처음에는 "정치(…)를 통해 베를린 상원은 SPD와 녹색당에 의해 통치되었다" [KS, S.20]. 그리고 실제로 베를린 의회는 1989년 여름에 학생 주도의 대학 프로젝트(Projekttutorien)에 대한 추가 자금 지원을 승인하여 학생들이 자금 지원을 신청할 수 있게 했다[6, US, S.4]. 인할츠-AG 회원들은 의학사 연구소의 현대사 연구소에 그들의 첫 집을 찾았다. 그들은 의학 이론, 생체인식 사회 모델, 튀레 폰 우엑스쿠엘의 아이디어를 다루는 독서 서클[18]을 설립했습니다.
Starting point was the “torso” of the “Inhalts AG”, the group that was founded during the strike to discuss study conditions, and the ten students who kept the group alive after the strike. They “pushed the plans forward to implement the Berlin reform model“ [17], initially “via politics (…), Hilde Schramm, a prominent parliamentarian of the Green Party – the Berlin Senate was governed by SPD and Greens –and there we were welcomed with open arms” [KS, S.20]. And indeed, the Berlin Parliament approved extra funding for student-led university projects (Projekttutorien) in summer 1989, which made it possible for students to apply for funding [[6], US, S.4]. Members of the Inhalts-AG found their first home at the Institute of History of Medicine, at the Research Unit for Contemporary History. They established a reading circle that addressed theories of medicine, the biopsychosocial model, and the ideas of Thure von Uexküll [18].

1989년 11월, 약 300명의 참가자가 참여한 첫 번째 워크숍 "개혁 의학 교육 – 내용, 구조 및 실현을 위한 단계"(Medizinischer Reformstudiengang – Inhalt, Strukturd Schritte zeiner Verwirklichung)가 시행되었다. 그것은 "베를린 연방 땅의 특별 프로그램을 통해 계획 그룹 RMC(PlaGru RMC)를 위한 자금 조달의 토대"를 마련했습니다[6]. 
A first workshop “Reformed Medical Education – Content, Structure, and Steps towards Realisation” (Medizinischer Reformstudiengang – Inhalt, Struktur und Schritte zu seiner Verwirklichung) was implemented in November 1989 with approximately 300 participants [6], [19], [20]. It prepared “the ground for financing the Planning Group RMC (PlaGru RMC) through a special programme of the Federal Land of Berlin” [6].

1990년 3월, PlaGru RMC는 4명의 과학자와 여러 명의 학생 직원들과 함께 운영을 시작했다. 이 단체의 리더는 루돌프 비르초 대학 병원의 학장인 디터 셰프너가 그의 부학장 요아힘 두덴하우젠의 지원을 받았다. 동시에, Westend 대학 병원의 의사들은 학습 목표에 대한 카탈로그를 작성하기 시작했습니다. 두덴하우젠은 다음과 같이 회상한다. "1989/90년 겨울이었을 겁니다." 또한, 교수진을 "비밀이 아닌, 일상의 일부로서" 배경에서 설득하기 위한 상당한 노력이 이루어졌다. 동료들의 문을 두드리는 것." [JD, S. 7]

In March 1990, PlaGru RMC began operation with four scientific and several student employees [20]. Head of the group was Dieter Scheffner, Dean of the University Hospital Rudolf Virchow, supported by his Vice Dean Joachim Dudenhausen. At the same time, medical doctors at the University Hospital Westend started to compile a catalogue of learning objectives. Dudenhausen recalls: “that must have been in winter 1989/90.” In addition, considerable efforts were undertaken to convince the faculty “in the background, not in secret, but not as part of daily routine. Knocking on colleagues doors.” [JD, S. 7]

PlaGru RMC는 여전히 존재하는 Humhts-Ag와 함께 혁신적인 교육 형식을 갖춘 단기 과정뿐만 아니라 워크샵과 회의 개최에 전념했습니다. 1991년 1월 초, 두 번째 워크샵 "의학 교육의 새로운 학습 및 교수 방법"(Neue Lern-und Lehrformen im Medizinstudium)이 열렸다[21]. 1992년 7월 Loccum Conference라고 불리는 세 번째 워크샵은 국제적인 촉진자와 참가자들을 끌어들였고 의료 교육 변화[22]라는 주제를 다루었다. 플라그루와 흡입츠-에이그 회원들은 다른 사람들에게 배울 목적으로 독일 비텐/헤르데케 대학, 맥마스터 대학, 미국 뉴멕시코 대학, 네덜란드, 트롬쇠와 린쾨핑의 스칸디나비아 개혁 대학, 스위스 베르나르 대학을 방문했다. 이러한 경험을 바탕으로 한 의료 교육 개혁(베를린 모델 커리큘럼)의 초안이 1992년 5월 과학 평의회에 제출되어 평가를 받았다. 그러다가 잠시 기세가 꺾였다. 베를린 모델 커리큘럼은 과학 위원회와 함께 평가를 받고 있었다. 책임은 명확하지 않았다. 그 상황은 위기를 초래했고 "개혁 그룹의 계약은 연장되지 않았다" [JD, S.10]
PlaGru RMC, together with the still existing Inhalts-Ag, dedicated itself to organising workshops and conferences as well as short-term courses with innovative educational formats. In early January 1991, a second workshop “New Learning and Teaching Methods in Medical Education” (Neue Lern-und Lehrformen im Medizinstudium) took place [21]. A third workshop called Loccum Conference in July 1992 attracted international facilitators and participants and dealt with the topic Changing Medical Education [22]. With the intent to learn from others, members of PlaGru and Inhalts-Ag visited the University Witten/Herdecke (Germany), McMaster University (Canada), the University of New Mexico (USA), Maastricht University (the Netherlands), Scandinavian reform universities in Tromsö and Linköping, and the University in Berne (Switzerland) [2]. A first draft of a medical education reform (Berlin Model Curriculum) based on these experiences was submitted for evaluation at the Scientific Council in May 1992 [20]. Then, the momentum was temporarily lost. The Berlin Model Curriculum was under evaluation with the Scientific Council. Responsibilities were not clear. That situation led to a crisis and “the contracts (of the reform group) were not extended” [JD, S.10]

1.2.2. 1993년부터 1996년까지의 위기, 재시동 및 침체
1.2.2. Crisis, restart, and stagnation 1993 to 1996

그 움직임의 엔진이 더듬거렸지만 멈추지는 않았다. Scheffner는 "두 번째 출발"을 시작했다[CK, S.10]. "월터 버거가 배에 올랐습니다. 그는 그 그룹의 첫 번째 새로운 과학 멤버였다. 그레고르 부인이 비서가 되었고 그 후 사정이 나아졌다." [CK, S.10. 월터 버거는 셰퍼가 그의 지지를 얻기 위해 그에게 접근했을 때를 회상한다: "버거 씨, 맥마스터 등 모든 것이 해결되었습니다. 이제 우리가 할 일은 그것을 베를린에 적응시키는 것뿐이다." [WB, S. 6-7]. 그러나 상황은 더 복잡했다. 새로운 팀은 "단순히 일을 인수하는 것은 어렵다. 대신, 모든 것을 처음부터 개발해야 합니다." [WB, S.7]. 따라서, "우리는 아담과 이브, 수천 가지 일들로 의학 교육에서의 이환율과 그들의 대표성에 대한 통계와 끝없는 토론으로 시작했다."[WB, S.7].

The engine of the movement stuttered but it did not stop. Scheffner initiated a “second start” [CK, S.10]. “Walter Burger came on board. He was the first new scientific member of the group. Mrs. Gregor became secretary and then somehow things got better” [CK, S.10]. Walter Burger recalls when Scheffer approached him to secure his support with the words: “You know, Mr. Burger, everything has been worked out, at McMaster and so on. The only thing we have to do now is to adapt it to Berlin” [WB, S. 6-7]. However, the situation was more complicated. The new team discovered, that “it was difficult to simply take things over. Instead, everything needs to be developed from scratch” [WB, S.7]. Accordingly, “we started with Adam and Eve, with thousand things, with statistics about morbidities and their representation in medical education and endless discussions” [WB, S.7].

1993년, FUB 의학부의 RMC 개발에 대한 참여를 촉진하고 문제 기반 학습(pbl)과 같은 새로운 학습 방법을 "조기 단계에서 교수진을 친숙하게" 하기 위해 조정 위원회(KoRa)가 설립되었다[23]. 하지만, 참가 요청을 받은 모든 사람들이 그것에 열광한 것은 아니었다. 예를 들어 해부학 교수(…)는 "매우 연극적인 방식"으로 사임했다[WB, S.7]. 그의 설명은 "그런 교육과정에 참여하는 것은 그의 양심과 동일시 될 수 없다"는 것이었다 [WB, S.7]. 한 약리학자는 이 모든 "에코와 정신적인 넌센스"가 불필요하며, "간호사 등"이 "목회 업무"를 담당한다고 자신의 의견을 표현했다[24]. "운명적인 만남"에 이르렀고, 일은 "정지 및 음모"로 표시되었고, 비공식적인 대화("노변한담")를 거듭하는 것이 필요하게 되었다. 모든 역경에도 불구하고, 소위 "흰 폴더"라고 불리는 "RMC의 성경"[KS, S.28]이 개발되었다. 여기에는 치료가 필요한 교육 목적, 내용, 질병 등이 담겼다. 후자는 모범적 성격(기본 프로세스와 원칙을 이해하는 데 중요), 긴급성(필수 행동 역량) 및 빈도에 따라 학제간 그룹에서 선택되었다[25].
In 1993, a Coordination Council (KoRa) was founded to promote the involvement of the FUB Medical Faculty into the development of the RMC and to “familiarise the faculty at an early stage” with novel learning methods such as problem-based learning (pbl) [23]. However, not everybody who was asked to participate was enthusiastic about it. The professor of anatomy for example (…) resigned in a “very theatrical manner” [WB, S.7]. His explanation was that “taking part in such a curriculum could not be squared with his conscience” [WB, S.7]. A pharmacologist expressed his opinion that all this “eco and psycho nonsense” was dispensable, and that “nurses and suchlike professions” were in charge of “pastoral work” [24]. It came to “fateful meetings”, work was marked by “standstill and intrigues”, and it became necessary to hold informal talks (“fireside chats”) again and again. Against all odds, the so-called “white folder”, the “Bible of the RMC” [KS, S.28] was developed. It contained educational objectives, contents, and diseases that required treatment. The latter were selected in interdisciplinary groups according to their exemplary character (important to understand basic processes and principles), urgency (essential action competence), and frequency [25].

그동안 훔볼트 대학교와 자유 대학교의 의과대학 통합이 본격화됐다. 교육 개혁가들에게 1995년은 다시 한번 침체를 가져왔다. 루돌프 비르초를 자유대학에서 분리해 훔볼트대학(…)에 편입시키기 위한 법적 요건을 마련하는 데 1년이 걸렸다. 그 해는 합병과 대항, 그리고 함께 싸우는 것으로 특징지어졌다. 다른 것을 할 시간이 없었습니다." [JD, S.7-8]. 
훔볼트 대학교의 의과대학인 샤리테의 많은 교사들이 "셰프너 개혁 사상"을 호의적으로 보았기 때문에 통합 과정 자체는 교육 개혁자들에게 긍정적인 것으로 입증되었다. 
In the meantime, the merging of the medical faculties at Humboldt University and the Free University was in full progress. For educational reformers, the year 1995 brought stagnation once again. “It took a year to draw up the legal requirements to detach the University Hospital Rudolf Virchow from the Free University and incorporate it into Humboldt University (…). That year was marked by merging and fights against and for and together and so on. There was no time for other things” [JD, S.7-8]. The merging process itself proved positive for educational reformers, because many teacher at the Charité, the medical school at Humboldt University, viewed “Scheffners reform ideas” favourably [[4] JD, S.7-8].

1.2.3 1996년부터 1999년까지의 구현 계획
1.2.3. Planning the implementation 1996 to 1999

1996년에 일의 우선순위가 바뀌었다. 이제, 자금 조달, 교수 개발, 커리큘럼과 교수 방법의 미세 조정 등이 점점 더 중요해졌다. 계획 그룹 PlaGru는 이러한 새로운 우선 순위를 반영하여 워킹 그룹(AG RMC)으로 이름이 변경되었습니다. 월터 버거는 그룹의 우두머리로 남았다. 4명 이후 5명의 학예사원을 모집했는데, 그중에서도 1세대부터 개혁가들을 모집했다. 구현 계획이 시작되었습니다. "교수 개발이 주요 이슈가 되었다." [JD, S.10] 개별 분야의 대표들과 함께 모듈을 계획하기 위해 다수의 작업 그룹이 설립되었다. "흰색 폴더"가 완료되었습니다. 미래 교사 풀을 만들기 위해 하빌리테이션(독일 박사후 자격)에 대한 법적 요구사항이 변경되었다. 새로운 규칙에 따르며, 그 자격을 원하는 모든 사람이 특정 세미나를 개최해야 한다고 규정했습니다 [JD, S.10].
In 1996, work priorities changed. Now, financing, faculty development, and fine-tuning of the curriculum and teaching methods became more and more important. The planning group PlaGru was renamed in working group (AG RMC) to reflect these new priorities. Walter Burger remained head of the group. Four and later five academic employees were recruited, among them reformers from the first generation. The planning of the implementation started. “Faculty development became a major issue” [JD, S.10]. A number of working groups was established to plan modules together with representatives of individual disciplines. The “white folder” was completed. To create a pool of future teachers, legal requirements for habilitation (a German postdoctoral qualification) were changed. The new rules stipulated that everybody who wanted to take that qualification must hold specific seminars [JD, S.10].

또 다른 쟁점은 자금 조달이었다. RMC는 의학부나 대학(예: 작업 그룹이나 기반 시설의 구성원들을 위한 기금)의 자금 지원을 받지 않을 것이 분명해졌다. 따라서, 다른 재원을 찾을 필요가 있었다. "제 기억으로는 Robert Bosch Foundation이 교육부 장관 회의와 함께 제공한 것으로 기억합니다. 만약 그들이 자금을 조달하지 않았다면, 베를린도 자금을 조달하지 않았을 것입니다." [JD, S.11]
Another issue was financing. It became clear that the RMC would not be financed by the Medical Faculty or University (e.g. funds for members of the working group or infrastructure). Therefore, it was necessary to find other financial sources. “The primary funding was provided by the Robert Bosch Foundation, as far as I remember, together with the Conference of Education Ministers (…) If they had not financed it, Berlin would not have financed it either” [JD, S.11]

베를린 상원 외에도 폴크스바겐 재단, 교육 기획 연구 촉진 위원회, 칼 구스타프 카루스 재단이 RMC에 자금을 지원하기로 합의했다. 그들은 모두 RMC의 이행을 촉진했다. 그러나, 그 프로젝트는 직원들에 대한 반복적인 단기 계약에서 증명되었듯이 여전히 위태로웠다.
In addition to the Berlin Senate, Volkswagen Foundation, Bund-Länder Commission for Educational Planning and Research Promotion, and Carl Gustav Carus Foundation agreed to fund the RMC. They all facilitated the implementation of the RMC. However, the project was still touch and go, as evidenced by repeated short-term contracts for the staff.

1999년 2월, 의사 면허 규정이 8번째로 개정되었고, 소위 "모델클레이즐"이라고 불리는 새로운 단락은 교육 개혁의 시험 프로젝트를 허용했다. 이는 베를린 RMC를 포함한 개혁된 의료 커리큘럼을 운영하기 위한 법적 틀을 제공했습니다. 불과 한 달 전 AGRMC는 "RMC 준비를 위한 연구 위원회"를 설립하기 위한 초안을 교수 위원회에 제출했습니다[26]. 교수진의 승인을 받은 요아힘 두덴하우젠은 연구 위원회의 의장이 되었다.
In February 1999, the Licensing Regulations for Doctors were amended for the eighth time, and a new paragraph, the so-called “Modellklausel”, allowed trial projects of education reforms. This provided the legal framework to run reformed medical curricula, including the Berlin RMC. Just a month earlier, the AG RMC had submitted a draft to the Faculty Board to establish a “Study Committee for the preparation of the RMC” [26]. Approved by the faculty, Joachim Dudenhausen became head of the Study Committee.

1999년 가을, 그 때가 왔다. 처음 63명의 의대생들이 RMC에 등록했는데, 이는 전통적인 교육과정과 병행하여 운영되었다. 학생 수가 적은 것은 평가 문제 때문이었다. 각각 21명으로 구성된 세 개의 세미나 그룹과 7명으로 구성된 9개의 PBL/커뮤니케이션 기술 그룹이 연간 코호트를 구성했다. 학생들은 RMC에 자원한 샤리테에 입학한 지원자들 중에서 무작위로 선발되었고, 따라서 교수진은 non-inferiority trial에 따라 다른 학생 그룹을 비교할 수 있었다. "모두가 엄청나게 낙관적이었다. 우리는 그 기간 동안 많은 것을 배웠다." [WB, S.14]
In autumn 1999, the time had come. The first 63 medical students enrolled in the RMC, which were run side by side with the traditional curriculum. The small number of students was due to evaluation issues. Three seminar groups with 21 students each and nine pbl/communication skills groups with seven students each made up the annual cohort. Students were randomly selected among candidates admitted at the Charité who volunteered to attend the RMC. The faculty was thus able to compare the different student groups in accordance with a non-inferiority trial [27], [28], [29]. “Everyone felt immensely optimistic. We (the AG RMC) learnt a lot during that time.” [WB, S.14]

처음에, 첫 번째 RMC 학생들은 꽤 짜증이 났다. 개혁 운동가 중 한 명은 "물론 학생들은 완전히 불안했다. 그들은 '우리가 어떤 것도 배울 수 있을까?'라고 물었다. 해부학자들은 학생들이 적절한 해부 과정이 없는 연구 과정으로 결코 건전한 의사가 되지 않을 것이라고 기쁘게 말함으로써 다시 한번 불명예스러운 역할을 했다. [WB, S.14]. 첫 주에, 그들은 추가 직원들이 아직 할당되지 않았기 때문에 예정된 과정을 취소할 것이다. 학장 요아힘 두덴하우젠의 여러 개입이 필요했다. 처음에는 엄청난 노력이 필요했지만, 결국 모든 것이 정착되었고 학문적인 일과 의학 교육이 시작되었다.

At first, the first RMC students were quite irritated. One of the reform activists recalls that “students were of course completely unsettled. They were asking ‘will we be able to learn anything at all?’ The anatomists played an inglorious role once again by gleefully stating that the students would never become sound physicians with a course of study lacking any decent dissection course” [WB, S.14]. In the first weeks, they would cancel scheduled courses, because additional staff hadn’t been allocated yet. Several interventions by Dean Joachim Dudenhausen were necessary. The beginning required enormous effort, but eventually things settled down and academic work and medical education commenced.

2. 구현: 구조, 내용 및 교육 방법의 원칙 또는: 그것을 혁명적으로 만든 이유
2. Implementation: principles of structure, content and educational methods, or: what made it revolutionary

RMC의 특징은 설계와 구현[30], [31]에 적용되는 여러 원칙이다. 다음 섹션에서는 이러한 원칙 중 가장 중요한 사항을 강조합니다.
The RMC was characterised by a number of principles that governed its design and implementation [30], [31]. The following section will highlight the most important of these principles.

• 미래의 의사: 생체 심리 사회적 모델 및 환자 중심의 의학
  
• 사례 기반 통합 학습
  
• 가르침에서 배움으로: 학생 중심 교육
  
• 내용에서 목표로: 교육 목표를 통한 건설적인 조정 및 커리큘럼 개편
  
• 공유된 계획 및 의사 결정: 교수에서 학제간 계획 그룹까지
  
• 타인에게서 배우기: 증거기반교육의 시행과 의료교육연구의 확립
  
• The future doctor: biopsychosocial model and patient-centred medicine
• Case-based and integrated learning
• From teaching to learning: student-centred education
• From content to objectives: constructive alignment via educational objectives and decluttering the curriculum
• Shared planning and decision making: from professor to interdisciplinary planning groups
• Learning from others: implementing evidence-based education and establishing medical education research

2.1. 미래의 의사: 생체 심리 사회적 모델과 환자 중심의 의학
2.1. The future doctor: biopsychosocial model and patient-centred medicine

RSM 개발 초기부터 "다른 종류의 의학"에 대한 요구가 존재했다. 이 운동은 튀레 폰 우엑스쿠엘, 한네스 파울리, 로베르트 비데르스하임[32], 그리고 "머르하르트 크라이"가 주도하여 시작부터 RMC의 아이디어와 개발을 지원하고 감독했다. 그 목적은 심리사회적 측면과 환자적 관점에 의해 전통적인 생물의학을 인식적으로 통합하도록 넓히는 것이었다. 머하르트 크라이스가 "의학의 위기"라고 묘사한 분석과 함께, 불만족스러운 의료 시스템에 대한 참가자들의 자신의 경험은 둘 다 그 요구를 야기했다. 그 위기는 의료 분야의 전문화 증가, 인구 통계학적 변화, 의료 노하우의 급속한 증가, 그리고 의학의 기술화의 증가로 특징지어졌다. 이 모든 측면은 특정 생명윤리학적 도전과 미래의 의사들을 위한 자격 프로파일의 변화와 관련이 있었다[1]. S.59f.
The demand for a “different kind of medicine” had been present from the very beginning of RSM development. The movement was spearheaded by Thure von Uexküll, Hannes Pauli, Robert Wiedersheim [32] and the “Murrhardter Kreis”, who supported and supervised the ideas and development of the RMC from the start. The aim was to broaden traditional biomedical medicine by psychosocial aspects and the patient perspective to epistemically consolidate medicine. The participants’ own experience with an unsatisfactory healthcare system, coupled with an analysis described by the Murrhardter Kreis as “crisis of medicine” had both given rise to that demand. That crisis was characterised by increased specialisation in the medical profession, demographic changes, a rapid increase in medical know-how, and an increasing technologisation of medicine. All these aspects were linked with specific bioethical challenges and a change of the qualification profile for future doctors [[1], S.59f].

의학교육에 관한 한 학위과정 초기 단계의 의학의 인식론적 토대에 대한 학술적 논의가 요구되었고, 아래와 같은 관점에서 과목을 탐색했다.

• 학제간 관점(예: 의학 이론과 실습의 원칙에 대한 세미나 및 소위 Studium Generale의 과외 학습)
  
• 조기 환자 접촉 및 실용적인 접근(특히 1차 진료에서 민간 진료의 초기 인턴십으로 구현) 
  
• 의사소통과 사회적 역량의 종적 커리큘럼의 구현

As far as medical education was concerned, there was a rising demand for an academic discussion of the epistemological foundation of medicine at an early stage of the degree course and the option to explore the subject from

• interdisciplinary perspectives (e.g. in seminars about principles of medical theory and practice, and extracurricular studies in so-called Studium Generale),
• early patient contact and practical approach (in particular in primary care, implemented as early internships in private practices), as well as
• the implementation of a longitudinal curriculum of communication and social competencies.

2.2. 사례 기반 통합 학습
2.2. Case-based and integrated learning

관점의 변화는 환자의 관점을 가르치기 위해 [징후에서 증상으로(진단부터 주관적 질병까지)] 특징지어지는 목표였다. 문제 기반 학습을 중심 학습 방법으로 구현한 것도 이러한 관점의 변화를 강조하는 한 가지 방법이었다. 이 과정에서 학생들은 환자가 보인 개별 증상(사례 기반 학습)으로 시작하여 학위과정 단계에 따라 기초 및 임상적 지식, 임상추리능력, 통합치료계획 수립에 필요한 기술을 습득하였다. 그 학습 과정은 학제간 세미나, 임상 기술 훈련, 실습 및 실험실 과정으로 보완되었다. 초반에는 강의가 전혀 예정돼 있지 않았다. 새로운 주제나 분야에 대한 첫 번째 개요를 제공하는 수시 강의는 학생들의 요청에 따라 이후 단계에서 시행되었다. 세미나는 항상 두 명의 선생님에 의해 열렸는데, 하나는 기초과학의 선생님이고 다른 하나는 임상 분야의 선생님이었다. 그 접근법의 이면에 있는 아이디어는 전임상 분야와 임상 분야의 분리를 극복하고 의료 업무의 학제 간 특성을 입증하는 것이었다.
A change of perspective was the aim, characterised from sign to symptom (from diagnosis to subjective illness), in order to teach patient perspective. The implementation of problem-based learning as the central learning method was one way to emphasise that change of perspective. In the process, students started with individual symptoms exhibited by a patient (case-based learning), thus acquiring basic and clinical knowledge, clinical reasoning skills, and the skills necessary for the generation of integrated treatment plans, depending on the stage of their degree course. That learning process was complemented by interdisciplinary seminars, clinical skills training, practical and lab courses. No lectures were scheduled in the beginning at all. Occasional lectures providing a first overview over a new topic or discipline were implemented at a later stage following the students’ requests. Seminars were always held by two teachers, e.g. one from basic science and one from a clinical discipline. The idea behind that approach was to overcome the separation of preclinical and clinical disciplines and to demonstrate the interdisciplinary character of medical work.

2.3. 교육에서 학습으로: 학생 중심 교육
2.3. From teaching to learning: student-centred education

RMC가 학생파업에서 비롯되었기 때문에 학생들의 자율성과 자기결정권이 또 다른 주요 쟁점이 되었다. 초기(1990년대 초)에는 교직원의 교사들이 학생들의 학습 과정을 저해할 수 있기 때문에 많은 자체 조직화된 PBL 그룹에서 그룹 촉진자로 환영받지 못한다는 것을 의미했다. 이후 이러한 급진적 입장은 pbl에 대한 경험과 전문성이 높아짐에 따라 수정되었고, 교사의 역할이 재정립되었다. 그들은 학습 과정의 "조산사" 또는 "촉매"가 되었다. 교수와 학습은 교사 중심에서 학생 중심으로 바뀌었다. 이것은 의료 문화의 급격한 변화를 구성했고, 보다 보수적인 교수진들의 반발과 저항의 주요 원인이 되었다. 그 발달은 한편으로는 학습 과정에 대한 통제력의 상실로 인식되었고, 다른 한편으로는 학생들에 대한 태도의 변화로 인식되었다: 무지한 어린이에서 자신의 삶을 책임지는 자결하는 어른으로. 위와 같은 관점에서 pbl이 [중심적 학습 방식]으로 구현되는 것은 불가피했다.

As the RMC had originated in a student strike, students’ autonomy and self-determination was another major issue. At the beginning (early 1990s), that meant for example that teachers from the faculty were not welcome as group facilitators in many of the self-organised pbl groups, because they would inhibit the students’ learning process. Later on, this radical position was modified as experience and expertise with pbl increased, and the role of teachers was redefined. They became “midwives” or “catalysts” for the learning process. Teaching and learning changed from a teacher-centred to a student-centred approach. This constituted a drastic change of medical culture and a major reason of opposition and resistance on the part of more conservative faculty members. That development was perceived as a loss of control over the learning process on the one hand, and on the other hand as a shift in the attitude towards students: from ignorant children to self-determined adults in charge of their own life. In view of the above, it was inevitable for pbl to be implemented as the central learning method.

[세미나, 임상 기술 훈련 및 실험실 과정에 참여하는 것]은 학생들이 교육 목표에 어떤 방식으로 접근할지 스스로 결정할 수 있는 기회를 제공하기 위해 자발적으로 이루어졌다. 학생들이 교실 행사에 정기적으로 참석한다는 것이 곧 드러났는데, 이는 교육 목표가 논의되고 학생들이 전문가들과 질문을 토론할 수 있는 기회가 있는 곳이었기 때문이다. 
Participation in seminars, clinical skills training, and laboratory courses was voluntary to give students the opportunity to decide for themselves in what way they would approach their educational objectives. It soon emerged that students regularly attended classroom events, because this was where educational objectives were addressed and where enabled students had the chance to discuss questions with experts.

미리 짜여진 교실 행사 외에도 자율학습을 위한 시간표가 넉넉하게 제공됐다. 자율학습(독일어권 국가 최초의 기술연구실 개발-임상기술 훈련센터-도서관 확장)을 지원하기 위해 필요한 인프라가 구축되었으며, 1학기 교육과정에 '학습을 위한 학습'에 관한 강좌가 포함되었다. 학생들은 [개별 선택 과목](임상 선택 과목, 연구 선택 과목, 의학 이론의 원리에 대한 세미나, Studium Generale)을 선택할 수 있었다. [팀워크가 필요하고 그 당시 쉽게 평가할 수 없는 역량에 초점을 맞춘 과목]만 필수로 지정되었고, 다음과 같다.

• pbl, 개인 실습 인턴십, 병원 병동에서의 근무 배치, 그리고 의사소통 기술 훈련. 즉, 항상 성찰과 연계된 과정(예: 환자 접촉 및 임상 환경에서의 경험)

후자의 경우 2000년부터 모의 환자가 배치되었다.
In addition to pre-structured classroom events, the timetable provided for plenty of time for self-study. The necessary infrastructure was established to support self-study (development of the first skills lab in German-speaking countries – the training centre for clinical skills TÄF – and the expansion of the library), and courses about “learning to learn” were included into the first-semester curriculum. Students were able to choose individual elective subjects (clinical electives, research electives, seminars about principles of medical theory, Studium Generale). The only compulsory courses were the ones that required teamwork and focussed on competencies that could not easily be assessed at that time:

• pbl, internship in private practices, work placements on hospital wards, and communication skills trainings, i.e. courses that were always linked with reflection (e.g. patient contacts and experience in clinical settings).

In the latter, simulated patients have been deployed since the year 2000.

2.4. 내용에서 목표까지: 교육 목표를 통한 건설적인 조정 및 커리큘럼 개편
2.4. From content to objectives: constructive alignment via educational objectives and decluttering the curriculum

사례 기반 및 문제 기반 학습과 관련하여 [자율 학습에 상당한 시간을 할애한 것]은 관련된 다음과 같은 결과로 이어졌다.

• 사전 구조화된 교육의 현저한 감소(예: 강의의 폐지, 해부 과정의 폐지) 및 
  
• 많은 교사들을 위한 수업 내용의 고통스러운 언쟁 

학습은 더 이상 체계학(예: 생리학 또는 내과)에 기반을 두지 않고 모범이 되었다. 학습 콘텐츠는 1차 진료 분야에서 일하는 주민들의 요구 사항에 따라 선정되었습니다. "의학의 전체 규범을 설명하는 것은 불가능했습니다. 그것과는 별개로, 지식은 너무 빨리 늙고 있다… 학생들은 그들이 모든 것을 결코 알 수 없고, 일반 의사, 자격을 갖춘 [일반의에게 중요한 것이 무엇인지를 인식하는 것]을 배울 수 있다는 것을 받아들인다. 이것이 당신이 가르쳐야 할 것입니다." [JD, S.13.
Case-based and problem-based learning in connection with substantial time allocated for self-study resulted

• in a significant decrease of pre-structured teaching (e.g. the abolition of lectures, the abolition of the dissection course) and
• in a painful decluttering of teaching content for many teachers.

Learning was no longer based on systematics (e.g. in physiology or internal medicine), but became exemplary. Learning content was selected in accordance with the requirements of residents working in the field of primary care. “It was not possible to explain the entire canon of medicine. Apart from that, knowledge is growing old too fast… Students just have accept that they can’t ever know everything and learn to recognise what is important for a general practitioner, a qualified general practitioner. This is what you should teach” [JD, S.13].

장기 또는 주제 기반 모듈의 개발은 교육목표를 기반으로 하였으며, 이를 인지목표, 응용목표, 정서목표로 세분하였다. 반복되는 주제와 증가하는 복잡성으로 인한 학습 소용돌이는 누적 학습을 용이하게 했다. 교육목표는 예정된 교육과정, 교육과정, 학습과정, 평가과정을 지배했다. 시험은 강의실 이벤트의 내용이 아닌 모듈의 목표를 평가했다. 시험은 학제간이었고 각 학기에 한 번의 필기시험과 한 번의 실기시험으로 제한되었다.
The development of organ or topic-based modules was based on educational objectives, which were subdivided into cognitive, applied, and affective objectives. The learning spiral with recurrent topics and increasing complexity facilitated cumulative learning. Educational objectives governed the scheduled, taught, learned, and assessed curriculum. Examinations assessed the objectives of the modules and not the content of classroom events. Examinations were interdisciplinary and limited to one written and one practical examination in each semester [33].

2.5. 공유 계획 및 의사 결정: 교수에서 학제 간 계획 그룹
2.5. Shared planning and decision making: from professor to interdisciplinary planning groups

또 다른 기본 원칙은 계획과 의사 결정 경로였다. 여기서 필요한 것은 서로 다른 분야와 지위 그룹 간에 협력적인 작업을 수립하는 것이었다. 개별 모듈의 목적과 내용은 단일 분야의 단일 대표자에 의해 결정되는 것이 아니라 학제간 그룹에서 논의되었다. 많은 교수들이 그 접근법에 익숙해져야 했다. 일부 교수들은 학생들이 공동 의사 결정자로 초대되는 것을 터무니없다고 여겼다. 이 접근법은 새로운 교육과정의 개발과 시행 과정에 모든 사람을 참여시키고, 헌신과 소유권을 확립하는 것을 목표로 했다. 즉, 변경 관리의 원칙을 구체적으로 적용하는 것이다.

Another basic principle was the planning and decision-making pathway. The requirement was to establish collaborative work among different disciplines and status groups. Objectives and contents of individual modules were discussed in interdisciplinary groups, rather than being determined by single representatives of single disciplines. Many professors had to get used to that approach. Some professors considered it outrageous that students were invited as co-decision-makers. This approach aimed at involving everybody in the process of developing and implementing the new curriculum, and at establishing commitment and ownership, i.e. specifically applying principles of change management [34], [35].

가장 높은 의사결정 기구는 새로운 모듈에 대한 모든 계획이 논의되고 승인되는 학습 위원회였다. 많은 RMC 직원들은 "열린 문에 대한 철학"을 따랐고, 교사나 학생 모두가 들어오거나, 긍정적이거나 부정적인 피드백을 주거나, 그저 "안녕하세요"라고 말하도록 초대받았다. 모듈 및 종적 과정에 대한 모든 워킹그룹을 설립하고 운영하는 것은 많은 노력이 필요했지만, 결국 동료들 간의 개인적인 교류와 교류의 토대가 되었다. 또한, 관심 있는 교사들이 AGRMC의 도움을 받아 교육과정의 일부를 평가하기 시작하면서 소규모 의료교육 연구 프로젝트를 탄생시켰다. 부분적으로 이러한 부분의 결과를 개혁된 교육과정과 나란히 존재했던 전통적인 의료 교육과정과 비교하였다.

The highest decision-making body was the Study Committee where all plans for the new modules were discussed and approved. Many RMC staff members followed a “philosophy of the open door” to signal that everybody – teachers and students alike – was invited to come in, to give positive or negative feedback, or to just say “hello”. Establishing and running all workings groups for modules and longitudinal courses required much effort, but it eventually constituted the foundation for personal interaction and exchange among colleagues. Moreover, it gave birth to small-scale medical education research projects, initiated by interested teachers who started to evaluate parts of the curriculum with the help of the AG RMC, partly by comparing outcomes of these parts with traditional medical curriculum that existed side by side with the reformed curriculum [e.g. [36], [37], [38], [39], [40]].

2.6. 타인으로부터 학습: 증거기반교육의 시행과 의료교육연구의 확립
2.6. Learning from others: implementing evidence-based education and establishing medical education research

이러한 프로젝트의 많은 부분이 실현된 이유는 혁신적인 교육 접근법이 상대적으로 작은 코호트로 시험될 수 있었기 때문이다. RMC가 출범한 이후 베를린의 개혁가들은 저명한 전문가들의 뛰어난 관대함으로부터 이익을 얻었다. 그들 중 일부는 베를린에서 안식년을 보냈다. 일부는 일주일 동안 와서 프로젝트의 개발을 지원했고, 예: 찰스 엥겔 (런던), 미리암 프리드먼 벤 데이비드 (던디), 콜린 콜스 (사우스햄프턴), 수 바티스트 (맥마스터 대학교, 해밀턴), 램버트 슈워스 (마스트리히트), 딕 모르텐슨 (스톡홀름) 등이 있다.

Many of these projects were realised because the innovative educational approaches could be tested with the relatively small cohorts. Ever since the RMC was launched, the reformers in Berlin benefited from the outstanding generosity of distinguished experts. Some of them spent a sabbatical in Berlin (e.g. Scott Obenshain from Albuquerque, Robert Wiedersheim from Witten). Some came for a week and supported the development of the project, e.g. Charles Engel (London), Miriam Friedman Ben-David (Dundee), Colin Coles (Southampton), Sue Baptiste (McMaster-University, Hamilton), Lambert Schuwirth (Maastricht), and Dick Mårtenson (Stockholm).

 

3. 진행 중인 업무: 개혁의 지속적인 추진
3. Work in progress: ongoing promotion of the reform

[변화 관리의 원칙]에 대한 열띤 토론은 RMC의 구현 및 최적화 단계를 표시했습니다. 필수 요소는 다음과 같습니다. 철저한 협의, 관련된 모든 당사자와의 대화(노변한담 및 비공개 대화 포함), 팀워크, 소유권 확립, 공유 책임, 위원회 활용 및 리더십 가시성 확립. 

The heated debate on the principles of change management marked the phase of implementation and optimisation of the RMC. Essential elements included:

• thorough consultation,
• talks with all parties involved (including fireside chats and private talks),
• teamwork,
• establishing ownership,
• shared responsibilities,
• harnessing committees, and
• establishing leadership visibility [34], [35].

외부 전문가뿐 아니라 교직원에게도 철저한 상담이 적용됐다.
Thorough consultation was applied to faculty members as well as to external experts.

외부 전문성을 보장하기 위해 자문위원회(AB)가 설립되었다. AB의 다른 구성원들은 2000년, 2002년, 2005년에 RMC를 검토하고 평가했다. 전문가는 다음과 같습니다. 앤 세프턴 (시드니), 찰스 엥겔스 (런던), 딕 모르텐슨 (스톡홀름), 세스 판 데어 블류텐 (마스트리히트)이 있다. 자문위원회으 권고안은 RMC의 다음 단계와 발전에 영향을 미쳤으며, 프로젝트 전반에 대한 감사를 표하는 동시에 전문가들도 건설적인 비판을 가했다. 때로는 교육과정에 초점을 맞추기도 했고, 또 다른 때는 학생들이 자기주도학습과 자율성을 가질 수 있는 기회를 비판적으로 검토하기도 했다. 그들은 항상 베를린 바깥까지 RMC의 영향을 줘야 한다는 것과, 교수진 개발과 참여의 중요성을 강조한다. 

An advisory board (AB) was founded to ensure external expertise. Different members of the AB reviewed and evaluated the RMC in 2000, 2002 and in 2005. Experts included: Ann Sefton (Sydney), Charles Engels (London), Dick Mårtenson (Stockholm), and Cees van der Vleuten (Maastricht). Its recommendations affected the next steps and developments of the RMC. While expressing their appreciation for the project as a whole, the experts also provided constructive criticism. Sometimes, they focussed on the curriculum, while another time they critically reviewed the students’ opportunity for self-directed learning and autonomy. At all times, they emphasises the importance of faculty development and participation as well as the impact of the RMC outside of Berlin.

2005년 마지막 평가에서, AB는 RMC가 여전히 너무 교사 중심적이며 전체 교수진의 참여가 아직 완전히 이행되지 않았다고 말했다. 샤리테에 대한 그들의 추천은 의학교육 연구를 커리큘럼과 학생들의 학습을 평가하는 중심적인 부분으로 보는 것이었다. AB는 "창의적인 방식으로 교육과정을 비판적으로 반영하고 다듬는 것"이 필요하다고 판단했다. 2002년, 그들은 후자가 "AG RMC에 필요한 많은 과제" 때문에 위험에 처해 있다고 보고 새로운 구조를 희망했다. 그런 관측 때문인지 연구위원회가 2003년 설치한 2005년 마지막 보고서에서 교육과정위원회 설립을 높이 평가했다. 설립의 목적은 "RMC를 비판적으로 평가하고 개선을 위한 권고안을 마련한다"였다.

In its last evaluation in 2005, the AB stated that the RMC was still too teacher-centred and participation of the whole faculty was not fully implemented yet. Their recommendation for the Charité was to view medical education research a central part of evaluating the curriculum and students’ learning. The AB considered it a necessity to “critically reflect and refine the curriculum in a creative manner.” [41]. In 2002, they saw the latter in danger because of the “large number of necessary tasks for the AG RMC” and they hoped for new structures. Probably because of that observation they appreciated the establishment of a curriculum committee in their last report in 2005, which was installed in 2003 by the Study Committee to “critically evaluate the RMC and work out recommendations for improvements” [42].

교육과정위원회(CoKo)는 16명의 위원으로 구성되었고 월터 버거가 위원장을 맡았다. 구성원은 임상뿐만 아니라 임상 전 분야의 전문가(생화학, 생리학, 의학 사회학), AGRMC의 회원, 그리고 두 명의 학생을 포함했다. 그들은 4년 동안 지속될 시간이 많이 걸리는 일을 맡았다. 그 결과 2005년 교수진에게 제시되어 샤리테의 개혁 및 전통 커리큘럼의 추가 계획의 기초로 승인되었다.
The curriculum committee (CoKo) consisted of 16 members and was headed by Walter Burger. Members included professionals from clinical as well as from preclinical disciplines (biochemistry, physiology, medical sociology), members of the AG RMC, and two students. They took up time-consuming work that would last for four years. It resulted in a competence-based catalogue of objectives, which was presented to the faculty in 2005 and was approved as the basis for further planning of the reformed and the traditional curriculum at the Charité.

또 다른 중요한 품질 보증 조치는 커리큘럼의 모든 부분에 대한 체계적인 내부 평가였다. 설문지와 토론 그룹은 학생들의 학습 진도와 학생과 교사들의 동기 부여를 평가하기 위해 사용되었다. 또한 평가결과를 전통교육과정 평가결과와 비교하였다. 또 다른 중요한 평가 도구는 RMC와 동시에 개발된 경과 의학발달시험(PTM)이었다. 개혁가 중 한 명은 "모듈에 대한 논의와 학기말 토론을 마무리했다"고 회상한다. 나는 우리가 항상 학생들을 진지하게 대했기 때문에 학생들이 신뢰를 얻었다고 생각한다. 우리는 항상 그들의 필요를 위해 노력했습니다 – 즉, 학생-중심이다. 모든 것이 지속적으로 최적화되었습니다. PBL 개념은 더욱 발전했고, 학생들은 그들의 학습 유형을 평가하기 위해 입학 시험을 볼 기회를 가졌습니다. 사람들이 경험한 위기 등에서 상담할 수 있는 기회가 많았습니다." [WB, S. 14-15]. 또 다른 리더십 과제는 사람들을 설득하고, 후원자 및 정치인들과 어울리며, 일상적으로 "소방 활동"을 수행하는 것이었습니다 [WB, S. 12].
Another important quality assurance measure was a systematic internal evaluation of all parts of the curriculum. Questionnaires and discussion groups were used to evaluate the learning progress of students and the motivation among students and teachers. Additionally, evaluation results were compared with evaluation results of the traditional curriculum. Another important evaluation instrument was the Progress Test Medicine (PTM), which was developed at the same time as the RMC [43]. One of the reformers recalls “concluding discussions of the modules and semester-end discussions. I think students have gained trust because we always took them seriously; we always tried to work towards theirs needs – student-centred. Everything was continuously optimised; the pbl concepts were further developed, students had the chance to take entrance tests to assess their learning type, a whole lot. There were many opportunities for counselling in crises that people experienced and so on” [WB, S. 14-15]. Another leadership task was to convince people, to socialise with sponsors and politicians, and to routinely perform “firefighting actions” [WB, S. 12].

 

 

4. 종료 및 변환
4. Termination and transformation

외부 자금 지원이 점차 사라지고 베를린의 학문적 지형 내에서 또 다른 합병 과정을 거치면서 RMC의 종말이 나타났다. 샤리테는 내부 자금으로 RMC를 지원할지 여부를 결정해야 했다. 그 의사 결정 과정은 2005년부터 2007년까지 2년 이상 지속되었다. 결국, "모든 학생을 위한 RMC의 확대는 (광범위한 노력으로 인해) 가능하지 않았을 것"이라는 생각이 지배적이었다[44]. 오직 "전통 교육과정의 통합, 개혁 요소의 이전"만이 가능했다[44]. 그것은 새로운 모델 커리큘럼의 탄생이었고, 적어도 공식적으로 샤리테의 모든 학생들에게 RMC를 제공하겠다는 정치적 의지를 따르기로 한 타협이었다. 동시에, "개혁적이고 전통적인 교과 과정의 검증된 부분" 중 어떤 것이 새로운 교과 과정에 통합될 것인지는 열린 채로 남겨졌다. 

With external funding phasing out and following another merging process within the Berlin academic landscape, the end of the RMC emerged. The Charité needed to decide whether to finance the RMC with internal funds or not. That decision-making process lasted from 2005 to 2007, more than two years. Eventually, the notion prevailed that an “expansion of the RMC for all students would not have been possible due to the extensive effort” [44]. Only “a synthesis, a transfer of reform elements in the traditional curriculum” [44] was feasible. That was the birth of the new model curriculum and a compromise to follow the political will to provide the RMC to all students at the Charité – at least formally. At the same time, it was left open which of the “proven parts of the reformed and traditional curriculum” were to be incorporated in a new curriculum.

이 문제를 밝히기 위해, 학장의 학생 사무소는 2007년부터 2010년까지 지속된 소모적인 과정을 시작했다. 따라서 [미래 교수와 학습의 초점과 관련하여 상당한 차이]가 있었고, 위에서 언급한 [변화 관리 과정이 전체 교수진에 도달하지 못했다]는 것이 밝혀졌다. RMC의 내용과 구조에 대한 심층적인 수정은 시간적 제약이나 의지의 부족으로 인해 불가능했다. 후자는 AGRMC의 회원들과 RMC의 다른 지지자들이 새로운 커리큘럼의 개발에서 지속적으로 기반을 잃었기 때문에 더 가능성이 있어 보인다. 
To shed light on the issue, the Dean’s office for student affairs started an exhausting process that lasted from 2007 to 2010. It thus emerged that there were substantial differences with regard to the focus of future teaching and learning and that the above-mentioned change management process had not reached the whole faculty. An in-depth revision of the content and structure of the RMC was not possible due to time constraints or perhaps also due to a lack of willingness. The latter seems more likely, seeing as members of the AG RMC and other supporters of the RMC had been continuously losing ground in the development of the new curriculum.

이것이 발터 버거가 샤리테를 떠난 이유였고, 거의 모든 RMC 설립자들이 그 뒤를 따랐다. 그러나 중추적인 아이디어는 베를린에서 독일어권 학술지형의 다른 곳으로 옮겨졌다. 2007년 베를린에서 열린 제1회 스킬랩 심포지엄과 의학교육협회의 '커뮤니케이션 및 사회적 역량' 위원회 설립과 같은 행사와 활동이 그 보급에 기여했다. 브란덴부르크 의과대학의 의학 커리큘럼에 RMC의 많은 원칙이 나타나게 되었다. RMC는 더 이상 과거의 형태로 존재하지 않으며 오늘날의 관점에서 그것의 종료를 피할 수 없었을 것이다. 그러나 독일어권 국가에서는 의학교육을 위한 실험과 실험의 장이 되었다. 개혁된 의학 교육을 경험할 수 있는 기회로부터 혜택을 받는 학생들뿐만 아니라, 이것이야말로 모든 모델 커리큘럼의 가치이다: 작은 학생들로 교육 혁신의 실현 가능성을 테스트하고 평가하며, 전통적인 커리큘럼의 많은 학생들도 이익을 얻을 것이다.

That was the reason why Walter Burger left the Charité, followed by nearly all founders of the RMC. However, pivotal ideas were carried from Berlin to other places in the German-speaking academic landscape. Events and activities like the first Skill Lab Symposium in Berlin in 2007 and the establishment of the Committee ‘‘Communication and Social Competencies’’ by the Association for Medical Education [45] contributed to that dissemination [45]. Many principles of the RMC became visible in the medical curriculum at the Brandenburg Medical School. The RMC does not exist anymore in its previous form and its termination could not have been avoided from today’s point of view. However, it served as a laboratory and experimental field for medical education in German-speaking countries. In addition to students benefitting from the opportunity to experience reformed medical education, this is the value of all model curricula: testing and evaluating the feasibility of educational innovations with small student cohorts, from which many students in traditional curricula will also profit.

학생들은 어떻게 되었는가?
What has become of the students?

11명의 코호트가 RMC를 통과했고, 거의 700명의 학생에 달한다. 2015년 졸업생들을 대상으로 한 설문조사는 이전 RMC 학생들이 어떻게 되었는지에 대한 질문을 조사했습니다. 164개의 응답(24%)을 기준으로 영상을 재구성할 수 있습니다. 그들의 업무 분야는 매우 다양하다. 졸업생 대부분은 베를린에서 일하며, 브란덴부르크와 노르트라인베스트팔렌이 그 뒤를 잇는다. 9명의 학생들이 해외에서 일하는데, 그 중 4명은 스위스에 있다. 임상적으로 거의 4분의 3이 일합니다. 34%의 응답자들이 연구 및 교육 활동을 언급하고 있다. 참가자의 27%는 아마도 대학 병원, 교육 병원 또는 교수 실습에서 일하는 사람들일 것이다. 가장 빈번한 전문 교육(시작 및/또는 완료)은 일반의학, 마취과, 소아과, 신경과였다. 돌이켜보면 98%의 응답자들은 RMC에 매우 만족하거나 만족했으며 자신의 진로에 대한 준비가 잘 되어 있다고 느꼈다.
Eleven cohorts passed the RMC, nearly 700 students. A survey of graduates in 2015 investigated the question of what has become of the former RMC students. An image can be reconstructed based on 164 responses (24%). Their fields of work are highly diverse. Most of the graduates work in Berlin, followed by Brandenburg and North Rhine-Westphalia. Nine students work abroad, four of those in Switzerland. Nearly three-quarter work clinically. Activities in research and teaching are mentioned by 34% reps. 27% of the participants, probably those who work at a university hospital, teaching hospital, or a teaching practice. Most frequent specialty trainings (started and/or completed) were general medicine, anaesthesiology, paediatrics, and neurology. In retrospect, 98% of the responders were very satisfied or satisfied with the RMC and felt well prepared for their career [46].

RMC의 일부는 여러 의학 교육 연구 프로젝트 및 대조군과의 비교 연구 내에서 효과성과 관련하여 분석되었다. 2005년 Bund-Länder 위원회에 대한 최종 보고서의 주요 수치는 예시로 여기에 나열되어 있다. 당시 RMC 내에서 학업을 시작한 학생은 316명으로 이 중 16명이 의학을 중퇴하거나 전통교육과정(5%)으로 전환했다. RMC 1차 코호트 중 18명(28.5%)이 국가고시 2차 시험(최소 학습 기간 내라는 의미)을 치렀고, 이에 비해 전통적인 교육과정에서는 23.5%였다. 국가고시에서 시험한 지식 습득과 관련하여 첫 해에는 두 코호트 사이에 큰 차이가 없었다. 2003년, 키슬링 외 연구진은 RMC의 1학년 학생들이 전통적인 트랙의 학생들보다 더 많은 지지를 받고 덜 스트레스를 받는다고 느낄 수 있었다. 샤리테 의과대학 1학년과 마지막 학년을 대상으로 한 전향적인 종단 조사인 이른바 KuLM 연구는 RMC 학생들이 전통적인 교육과정 학생들에 비해 자신의 교육과정 만족도가 높고 스트레스 수준이 낮은 것으로 나타났다. 지난 해 RMC 학생들은 전통적인 트랙의 학생들보다 미래의 전문적 요구 사항을 고려하여 그들의 역량을 더 높게 평가했다. 저자들은 의사소통 능력과 실무 능력의 차이를 특히 극단적으로 고려했으며, 두 역량 모두 RMC의 특정 강점으로 정의했다.
Parts of the RMC were analysed with regard to its effectiveness within several medical education research projects and comparison studies with control groups [27-29]. Key figures from the 2005 final report to the Bund-Länder Commission are listed here as an example. At that time, 316 students started theirs studies within the RMC. Of those, 16 students either dropped out of medicine or switched to the traditional curriculum (5%). Of the RMC first cohort, 18 students (28.5%) took the second part of the state examination (which meant within minimum duration of study), compared with 23.5% in the traditional curriculum. There were no significant differences between the two cohorts in the first years regarding the acquisition of knowledge as tested in the state examination [47]. In 2003, Kiessling et al [28] were able to show that first-year students in the RMC felt more supported and less stressed than students in the traditional track. The so-called KuLM study, a prospective longitudinal survey with first-year and last-year medical students at the Charité, showed that RMC students were more satisfied with their curriculum and experienced lower stress levels than students in the traditional curriculum. Last-year RMC students assessed their competencies with regard of future professional requirements as higher than students in the traditional track. The authors considered the differences regarding communication skills and practical skills particularly drastic, and both competencies were defined as a specific strength of the RMC [48].

과거의 학생들은 오늘날의 선생님이고 아마도 미래의 의사 결정자들일 것이다. 우리는 독일 의료 시스템의 어려운 근무 조건에도 불구하고, 졸업생들이 의사 결정자의 위치에 서게 되면 [RMC의 기본 원칙]을 기억하기를 바란다. [환자-치료 접근법, 자기 결정적 작업, 의사 결정 공유, 타인으로부터의 배움]이라는 "다른 종류의" 의학.

The students of the past are the teachers of today and perhaps the decision-makers of tomorrow. We hope that, despite the existing difficult working conditions in the German healthcare system, graduates do remember the basic principles of the RMC, once they find themselves in the position of decision-makers: a “different kind” of medicine with a patient-centred approach, self-determined working, shared decision-making, and learning from others.

 

---

GMS J Med Educ. 2019 Oct 15;36(5):Doc62. doi: 10.3205/zma001270. eCollection 2019.

The Berlin reformed curriculum in undergraduate medical education: a retrospective of the development history, principles, and termination

Jutta Begenau 1, Claudia Kiessling 2

Affiliations collapse

Affiliations

1Charité - Universitätsmedizin Berlin, Berlin, Germany.

2Universität Witten/Herdecke, Fakultät für Gesundheit, Lehrstuhl für die Ausbildung personaler und interpersonaler Kompetenzen im Gesundheitswesen, Witten, Germany.

PMID: 31815172

PMCID: PMC6883246

DOI: 10.3205/zma001270

Free PMC article

Abstract 

in English, German

The Reformed Medical Curriculum (RMC) at Charité-Universitätsmedizin Berlin was launched in autumn 1999, while medical schools in Canada, the United States, Scotland, the Netherlands, and Scandinavia already had adapted educational reforms in medical education many years before [1], [2]. For eleven years, 63 medical students per year trained at the Faculty in accordance with international standards governing the RMC. It was the first and perhaps most revolutionary reformed medical curriculum at a German university after the commencement of "Modellklausel", a new section in the Licensing Regulations for Doctors (Approbationsordnung für Ärztinnen und Ärzte) in 1999 that paved the way for fundamental reforms within undergraduate medical education in Germany. The idea was to establish and test a "pilot project of a fundamental reform of medical education in Germany" [3], thus aligning Germany with international developments and establishing a model for other reform initiatives. The first part of the article will provide an overview of how the RMC were able to emerge. It reports who initiated the project and why, who kept it running and encountered opposition and what were the social and political conditions. The second part of the article describes the principles that were fundamental for the development of the RMC. The third part illustrates the quality assurance measures, and the final section covers the termination of the RMC.

Keywords: problem-based learning; reformed medical curriculum; undergraduate medical education.

Copyright © 2019 Begenau et al.