의학교육에서 포트폴리오 학습의 활용(The use of portfolio learning in medical education) ●

The use of portfolio learning in medical education

DAVID SNADDEN & MARY THOMAS

Tayside Centre for General Practice, University of Dundee, Scotland, UK

포트폴리오 학습이란 무엇인가? What is portfolio learning?

포트폴리오에는 '학습과 관련된 문서'들, 그리고 '그로부터 무엇을 배웠는가'에 대한 설명이 포함된다. '학습과 관련된 문서'는 다음의 것들을 포함한다.

In practice portfolios include documentation of learning, and an articulation of what has been learned. The documentation can include:

· records of events or experiences;

· lists of critical reviews of articles read;

· projects carried out;

· teaching sessions attended;

· videoclips, educational events and patients seen.

'그로부터 무엇을 배웠는가' 에는 다음의 것들이 포함된다.

The articulation of what has been learned may include: 

· written reflective accounts of the events documented;

· personal reflections kept in the form of a journal or diary.

문제가 무엇인지, 무엇을 배웠는지, 앞으로 무엇을 더 배워야 하며 그 계획은 어떻게 되는지에 대한 성찰이 포함된다.

These would include reflections on problem areas, what has been learned, what has still to be learned and plans for how new learning will be tackled.

배경 The background to portfolio learning in medical education

포트폴리오가 새로운 것은 아니다.

Portfolios are not new,

평가도구로서도 매력적인데, 일정 기간에 걸쳐 임상 수행능력을 평가할 수 있을 뿐만 아니라, authentic assessment의 한 방법이기도 한다.

They are also attractive as assessment tools in that they have a potential to assess clinical performance over a period of time, constituting one form of authentic assessment

학습에 따라서 학습자의 행동, 직관, 수행능력이 달라진다. 성인학습자적, 자기주도적, 성찰적 학습은 수동적 학습을 장려하는 환경에서는 일어나기 힘들다.

In other words learning which impacts on the behaviour, intuition and performance of the learner. Adult, self-directed and reflective learning are deemed less likely to occur in environments where passive learning is encouraged,

Brookfield와 Boud는 교육 프로그램 자체가 성찰적인 요소(reflective component)를 포함함으로써 상호작용을 촉진시켜야 한다고 주장했다.

Brookfield (1986) and Boud (Boud & Walker, 1993) suggest that educational programmes should be interactive, include reflective components and be related to experience.

포트폴리오 학습 : 미국 교육 시스템에서의 발전 
Portfolio learning: its development in the American school system.

비록 포트폴리오가 그래픽아트 분야에서 오랜기간 사용되어오긴 했지만, 북미 교육 시스템 내에서 포트폴리오는 성찰을 촉진시키기 위한 기제였다.

Portfolios as mechanisms to enhance reflection were developed within the North American school system - though it could be argued that portfolios in terms of the graphic arts have been in existence for many years.

포트폴리오 학습은 빠르게 도입되었으나, 평가 측면에서 포트폴리오의 활용과 개발에 대한 평가는 제대로 이루어지지 않은 채 도입된 것이었다.

The rapid adoption of portfolio learning, including its use in assessment, seems, however, to have been implemented with little true evaluation of the use and development of portfolios

평가자들간의 컨센서스는 쉽게 달성되지 않았고, 준거, 효과적 수련, Rubric, 상식(Common values), 학생 수행능력에 대한 이해 등에 따라서 많이 달라졌다. 

Consensus amongst raters was not achieved easily and depended on clearly articulated criteria, effective training, and rubrics that reflected shared experience, common values and a deep understanding of student performance.

그럼에도 불구하고 포트폴리오 평가의 도입은 교사들의 활동에 영향을 주었다.

Nevertheless the implementation of portfolio assessment seems to have influenced the activity of classroom teachers.

이들 초등학교 프로젝트는 포트폴리오 기반 학습이 학교에서 이루어지는 것이 교사와 학생 모두에게 쉽지 않은 일이지만, 교실의 분위기를 드라마틱하게 바꾸고, 교사-학생간 상호작용의 특성을 변화시켰으며, 학생과 교사 모두가 활발하게 평가를 위한 준거를 개발하고 적용시키는 모습으로 바꾸어놓았다. 

These elementary school projects lead to the conclusion that portfolio-based learning, in the school context, is challenging for teachers and students, can dramatically alter the climate of the classroom and the nature of teacher/student interactions and has brought assessment into the classroom with students and teachers actively engaged as they generate and apply criteria to each other’s work.

간호학과 의학에서의 포트폴리오 Portfolios in nursing and medicine

영국에서 포트폴리오는 간호학 교수들에 의해서 전격적으로 도입되었으며, 지금은 간호사와 조산사 수련 기관에서의 형성평가와 총괄평가를 위해서 사용되고 있다. 

In the UK portfolios have been adopted with enthusiasm by the nursing profession and are now used for both formative and summative assessment in several nurse and midwifery training institutions (Jasper, 1995a) and have also been supported by the UK Central Council for Nursing and Midwifery to track professional development (Jasper, 1995b).

하지만 다음과 같은 문제가 드러났다.

· 개별적 평가와 대규모 평가에서 활용시 갈등 There may be conflict for portfolios serving both the purposes of individual learning/assessment and large-scale assessment.

· 업무가 표준화되지 않은 상태에서 포트폴리오 평가가 가능한가? Can portfolios be assessed if the work is not standardized?

· 학생의 태도, 감정, 행동을 평가하는 준거는 무엇이 되어야 하는가? What criteria should be involved in making judgements about students’ attitudes, feelings and behaviour?

· 프라이버시와 기밀과 같은 개인적인 내용은 어떻게 해야 하는가? What about issues of privacy and confidentiality as some portfolios contain highly personal material?

교사들은 포트폴리오가 좋은 학습 도구라고 생각했다.

the tutors felt that a portfolio was a valuable learning tool from their point of view and that of their students.

학생측에서 가장 큰 문제는 무엇을 해야하는가에 대한 불확실성에 대한 걱정과 개인적 감정을 기록하는 것에 대한 불안감이었다.

The main problems for students were uncertainty regarding what was expected of them and anxiety about recording personal feelings..

Glen과 Hight는 영국 간호사와 조산사 교육에서 포트폴리오를 논하면서, 포트폴리오의 주요 기능은 교육 변화의 촉매재라고 하였다. 즉, 포트폴리오를 만드는 과정이 그 결과보다 중요하다는 것이다.

Glen & Hight (1992), writing on the place of portfolios in nursing and midwifery education in the UK, also raised the question of whether the main function of portfolios was that of a catalyst for educational change, in other words was the process of developing portfolios more important than the product.

포트폴리오 기반 학습은 이제 영국의 일반진료에도 적용되고 있다.

Portfolio-based learning has now been actively promoted in general practice in the UK.

Practitioner와 Mentor가 함께 일하는 방식으로 GP에 대한 보수교육의 목적으로 활용되었다.

Portfolio development in general practice has continued with descriptions of portfolios being used to support continuing education for established general practitioners in which practitioner and mentor work together, the practitioner then submitting a portfolio which is assessed against a number of criteria to allow the award of postgraduate education credits (Treasure, 1996; Challis et al., 1997).

이 시점에서 포트폴리오와 로그북의 차이를 강조하는 것이 필요할 것이다. 로그북은 수행한 업무의 모음으로서 비판적 성찰을 담고 있지 않으며, 학습을 촉진한다기보다는 정기적으로 하는 업무(chores)에 가깝다.

It is perhaps important, at this point, to emphasize the difference between portfolios and the log-books that have been introduced into some higher specialist training programmes. Such log-books are collections of tasks carried out, they do not contain critical reflections and may be seen as chores rather than as a way of stimulating learning

포트폴리오는 자신의 수행에 대한 비판적 성찰을 담고 있으며, 로그북에서는 이루어지지 않는 새로운 방식의 학습이 이뤄진다.

Portfolios contain critical reflection on practice and as such challenge the learners’ performance and learning in a way that log-books do not.

교육자들 사이에서는 포트폴리오 기반 학습이 유명해졌지만, 여전히 이론가들이나 교육과정을 조직하는 사람들은 여전히 몇 가지 의문을 갖는다.

Despite the popularity of portfolio-based learning amongst educationalists, theorists and course organizers there still seem to be a number of outstanding questions:

· What do learners think of portfolio learning?

· What is the effect of portfolio learning on their education?

· Is there a valid assessment component?

· Is there a place for these ideas in general medical education?

이 질문들은 Scottish General Practice Training Regions에서 두 연구에 의해서 설명되었다. 

These questions were addressed in an action research project carried out in two Scottish General Practice Training Regions (Tayside and Highland) which has helped develop a number of principles concerning how portfolio learning can be developed in general practice and whether it has a place.

의학교육에서 포트폴리오 개발 Developing a portfolio in medical education

포트폴리오는 어떻게 생겼는가? What does a portfolio look like?

사용자가 만족한다면 어떻게 생겼는지는 중요하지 않다.

It really does not matter as long as the user is happy with it.

포트폴리오란 무엇인가? What is in a portfolio?

포트폴리오의 구성요소들은 성인학습자 그리고 성찰적 학습(reflective learning)의 개념에 기반하고 있다. 학습과정에 걸쳐서 스스로의 요구와 아젠다를 설정해야 하며, 자신의 임상수행, 그 기간동안 어떤 경험을 했는지도 설명할 수 있어야 한다. 

The components of a portfolio described here are based on the concepts of adult and reflective learning. Throughout learners are asked to identify their own needs and agendas, often through reflection on their own clinical practice and experiences they have in their learning period.

다음은 포트폴리오에 들어갈 수 있는 것들이다.

The following are examples of what a portfolio can contain:

· critical incidents of events with patients;

· a reflective journal or diary;

· tutorials and learning plans, and re¯ection on them;

· routine clinical experiences;

· exam preparation material;

· video recordings of consultations and other relevant material;

· audits and project work;

· critical reviews of articles;

· feedback material;

· management material.

• Critical incidents of events with patients. Critical incidents are those incidents in a working day that are memorable for going well or going badly. (특별히 기억에 남거나 잘 하지 못했던 것들)
  
  
• A reflective journal or diary. Again this does not need to be extensive, but does require some discipline in committing thoughts to paper. The benefit of this is that it encourages learners to reflect on what they are doing, what they are finding difficult and what they are trying to plan for. 
  
  
• Tutorials and learning plans. Descriptions of tutorials that have happened and the follow up of learning needs that have resulted from them can be useful, but more important are some brief reflective notes on which areas within the tutorial were identified as strengths, and which as problem areas for the particular leaner.
  
  
• Routine clinical experiences. There is a lot of routine work in medicine, therefore it is important to focus occasionally on routine incidents in the same way that critical incidents are described above.
  
  
• Exam preparation material. Exams and assessments are an inevitable part of education. Most students and young doctors prepare for examinations through course work and material collected from this and reflection on these can help in their preparation.
  
  
• Video recordings of consultations and associated material. Communication training is now commonplace in medicine and videos of simulated and genuine clinical consultations are used more and more to teach and assess progress in this area.
  
  
• Audits or other project work carried out. Similarly, audits and other project work can form part of a portfolio, again giving evidence of work carried out.
  
  
• Articles and texts reviewed critically. Current emphasis on critical appraisal suggests that all students and doctors should be able to review articles and books critically.
  
  
• Anything else. The important thing is to give learners freedom in what they collect and how, so anything else they wish to include can become part of a portfolio.

포트폴리오는 어떻게 활용할 수 있는가? How can the material in a portfolio be used?

몇 가지로 활용될 수 있다.

- 개인적 발전을 추척하는 방법

- 토론을 촉진하고 미래 학습의 계획을 세우는 Formative Learning

- 공식적(총괄)평가 도구

Portfolios can be used in a number of ways:

· as a method of personal development and a way of tracking progress;

· formatively as a learning tool to stimulate discussion and to plan future learning;

· as a formal (summative) assessment tool.

개인적 발전을 추척하는 방법으로서의 포트폴리오
As a method of personal development and a way of tracking progress. 

포트폴리오는 튜터나 멘토의 지원 없이도 자기주도학습의 목적으로 사용될 수 있다.

Portfolios can be used for self-learning as a personal activity without support and input from a tutor or mentor.

그러나 튜터의 지원이 없는 상태에서 포트폴리오를 만드는 사람은 거의 없을 것이다. 포트폴리오와 그 주변 시스템을 세팅할 때 효과적인 튜터와 멘토의 네트워크는 그 시스템의 성공에 있어 매우 중요하다.

Lack of tutor support, however, will mean that few will create a portfolio. In setting up any system based around portfolios an effective network of tutors and mentors will be important in determining the effectiveness and success of the system.

토론을 촉진하고 미래 학습 계획을 세우는 도구로서의 포트폴리오

Formatively as a learning tool to stimulate discussion and to plan future learning. 

어떤 포트폴리오든지 그것이 활용되는 과정에 따라 그 유용성이 달라진다. 비록 스스로 성찰하는 것이 종종 도움이 되지만, 진정한 의미의 성찰은 다른 사람(튜터)의 도움이 필요하다.

The content of any portfolio is only as useful as the process by which the materials is used. Although reflecting to oneself through a reflective journal is therapeutic for some, real and challenging reflection requires another person, the trainer or tutor.

다음의 스텝을 따르게 된다.

Step 1

The learner:

· identifies an experience-this may be from an entry in the portfolio,

· describes it.

The trainer:

· listens actively-this means using verbal and non-verbal encouragement;

· is not judgmental;

· avoids interpretations;

· only challenges statements that are at odds with behaviour

Step 2

The learner:

· reflects on the experience trying to identify what has been learned.

The trainer:

· clarifies;

· summarizes;

· reflects what the learner has said;

· does not interpret.

Step 3

The learner:

· identifies new learning needs;

· devises a plan to met these.

The trainer:

· facilitates this process;

· may now suggest answers or offer advice, but must make it clear that there may be other answers.

이 과정에서 도움이 될 만한 질문은 다음과 같은 것들이 있다.

Here are some examples of the sorts of questions that can be helpful in this process:

· What happened?

· What did you notice/find intriguing/exciting/worrying?

· What could you learn from this?

· How would you go about learning it?

· How would you know you have learned it?

이러한 과정이 끝나면, 포트폴리오를 이용한 학습 계획을 세워야 한다. 학습의 다음 단계가 무엇인지 적어보는 것은 나중에 진짜로 그것을 달성했는지, 혹은 어떤 행동이 이뤄졌는지 확인하는데 중요하다. 또한 포트폴리오는 피드백 기회를 제공하기도 한다.

At the end of all this it is important to commit to the portfolio some sort of learning plan. Writing down the next steps in a learning process is an important way of checking up later to see what has happened or what action has been taken. In addition to this the portfolio can give a valuable opportunity to stimulate feedback.

공식적(총괄) 평가도구로서의 포트폴리오

As a formal (summative) assessment tool. 

포트폴리오는 어느 기간에 걸친 수행능력을 평가하는 한 방법으로서 매력적인 평가도구이다. 즉, 이론을 잘 적용하는지, 수행능력이 어떠한지를 평가할 수 있다. 이것을 Authentic assessment라 부른다. 그러나 공식적 평가 목적으로서 포트폴리오를 활용할 경우 순수하게 학습적 목적으로 활용할 경우와 전혀 다른 내용이 들어갈 수 있다는 것이 강조될 필요가 있다.

Portfolios are attractive as assessment tools as they appear to be one way of assessing performance in practice over a period of time, in other words they assess the application of theory and the performance of the student or doctor. This is now called an authentic assessment. It must be stressed, however, that if portfolios are to be used for formal assessment purposes learners may keep quite different material than if the portfolio is to be used for purely learning purposes.

공식적 평가는 어떤 자료가 수집되는가에 있어서 부정적 영향을 주기 쉽다.

negative impact formal assessment would have on the material collected

포트폴리오를 평가하기 어려운 한 가지 이유는, 그것이 개인적 내용을 담고 있기에 객관성이 거의 없으며, 학생간 의사간 비교가 어렵게 된다는 점이다. 평가는 또한 노동집약적인데, 평가자는 학습자의 목표와 그에 따라 어떤 근거를 수집하였는지를 꼼꼼히 살펴보아야만 한다.

One of the reasons that portfolios are difficult to assess is that they contain personalized material with few points of objectivity that allow comparisons to be made between students or doctors. Assessment is also labour intensive and requires careful reading and response to a learner’s objectives and evidence of whether they have been met. 

개인적 학습과 성장을 촉진하는 기전으로서는 효과적이나 비교를 위한 평가에는 어려움이 있다.

This means they are effective as mechanisms to support and facilitate personal learning and growth, but cumbersome in comparative assessments.

대규모 포트폴리오 평가의 질에 대한 연구는 거의 없으며, 지금까지 이뤄진 것도 대부분 미국 학교 시스템 내에서 이루어져왔다.

There is little research available in the literature on the technical quality of large-scale portfolio assessments, and what has been done is largely within the American school system.

새로운 평가 방법이 학습에 대한 새로운 아이디어로부터 만들어져야 하는 어려움과 포트폴리오 평가의 어려움을 말해준다.

This illustrates the difficulties in assessing portfolios and how new methods of assessment will need to be developed in the context of new ideas on learning.

평가에 대한 전통적인 관점에 사로잡혀 있다면 포트폴리오의 효과적 평가는 어렵다. 다른 말로 하면, 학생간 서로 비교하여 학점을 주고, 점수를 주는 것은 본질적으로 비-표준화된 방법인 포트폴리오에 적합하지 않은 것이다. 포트폴리오는 비-비교적 평가 방법이 개발되기 전까지는 평가가 어려울 수 밖에 없다. 

This in essence means that the effective assessment of portfolios will continue to be difficult if we remain trapped within our traditional view of assessment. In other words, assessment based on comparing students with each other and with issuing grades or marks does not fit easily with portfolios which are essentially non-standardized. Portfolios will remain difficult to assess until new non-comparative assessment methods are developed. While the emphasis on grading, excellence and comparison between students and doctors remains in assessment and medicine, it is likely that portfolios will have a greater place as a learning tool than as a summative assessment tool,

포트폴리오의 개념을 어떻게 도입할 것인가? How do you introduce the concept of portfolios?

포트폴리오는 다양한 방법으로 사용가능하며, 학생과 의사 모두에게 포트폴리오가 무엇을 위해 사용되고, 어떻게 사용할 것이 기대되는지를 명확히 해줘야 한다. 몇 개의 ground rule 이 매우 중요하다.

Also, as portfolios can be used in a number of ways it has to be absolutely clear for students and doctors what the portfolios will be used for and how they are expected to use it. For this reason the early establishment of some ground rules is very important

Ground rules.

· 포트폴리오에 쓰인 것은 누가 보는가? Who sees what is written in the portfolio?

· 누가 포트폴리오를 쓸 수 있는가? Who can write in a portfolio?

· 쓰여진 내용에 대해서 어떤 일을 하게 되는가? What will happen to the written material?

· 평가는 어떻게 되는가? Where does assessment ®t in?

· 언제 포트폴리오가 사용되며, 시간은 얼마나 할당되는가? When will the portfolio be used and how much time will be set aside for it?

· 어디에 보관될 것인가? Where it will be kept?

아래는 위에 대한 몇 가지 아이디어들이다. 

Here are some ideas on these topics that have come from our research. These may seem a bit restrictive, but they help give learners a feeling of control and confidence at the start of using a new learning system. In practice they become quite open with their portfolios as they represent a record of their development; the ground rules, however, are essential in allowing this openness to develop

누가 보는가? Who gets to see the portfolio?

의무기록과 비슷한 수준의 보안이 유지되는 것이 중요하다.

it is important that they are treated with the same degree of confidentiality as any medical record

가장 효과적인 성찰 코멘트는 교사와 학습자가 정기적으로 볼 때 가능하다.

The most effective reflective comments seem to be those that both trainer and learner regularly see.

누가 쓰는가? Who writes in it? 

어떤 부분은 교사와 학습자의 기여가 모두 포함될 수 있다.

Some portfolios may contain contributions from trainer and learner. 

어디에 사용되며 얼마나 시간이 배정되는가?

When will the portfolio be used and how much time will be set aside for it? 

학습자의 요구에 맞는 교육과정 개발에 사용될 수 있음. 

Used imaginatively a portfolio will help develop a curriculum for a student or doctor that is relevant to a learner’s needs.

쓰여진 내용에 대해서 어떤 일을 하게 되는가? 

What happens to the written material in the portfolio?

학습자의 포트폴리오는 자기자신의 것이며, 훈련에 관한 자기만의 기록이다. 무엇이 될 것인가는 학습자에 달렸다.

Learners’ portfolios are theirs, they are their own personal record of their training, it is up to them what happens to them.

시작하기 

Getting started

가장 중요한 것은 교수와 학생에게 어떻게 사용할 것인지 정보를 주는 것이다.

More important is the information that is given to faculty and students on how to use portfolios

교수와 학생에게 포트폴리오와 친해지게 하기

Workshops to familiarize faculty and students 

대부분의 의사와 학생은 포트폴리오 학습에 대한 우려가 해소될 때 까지 사용하려고 하지 않을 것이다. 교사와 학습자를 모두 모아놓고 이 장애물을 해결하기 위해서는 토론과 도전을 통해서 아이디어를 모아야 한다.

Most doctors and students will not consider portfolio learning unless some of their concerns and apprehensions are dealt with. Bringing groups of learners and teachers together to explore ideas through discussion and challenge is fundamental in dealing with some of these barriers.

워크숍을 통해서 우려를 해소하고, ground rule을 개발하고, 앞서 언급된 세 개의 튜토리얼 스텝을 연습할 수 있다.

Workshops can deal with concerns, develop ground rules, refine written notes and help staff practice the three tutorial steps described earlier.

워크숍에서 중요한 부분은 포트폴리오를 사용한 사람과 사용하지 않은 사람이 서로 만나는 것이다.

An important part of any workshop is to meet others who have and have not used portfolios

또한 다른 전공의 사람을 만나는 것도 마찬가지로 중요하다.

Equally important is exposure to people from other disciplines

FAQ

Some frequently asked questions

시간이 많이 드나요? Does keeping a portfolio take a lot of time?

Portfolios do take a little time, but not as much as first imagined. In many ways portfolios are a parallel to medical records. Few doctors see patients without writing something down about them to help them next time they or their colleagues see a patient.

A few minutes at the end of each day is all that is needed

상호 관계에 영향을 미치나요? Does a portfolio influence relationships?

This is a difficult question to answer.

Where the relationship is good portfolios seem to work well, but they are less likely to do so where the relationship has some problems.

모든 사람이 만족하나요? Is everyone happy to use a portfolio?

No. Some learners have great difficulty seeing the relevance of intense reflective learning. Young doctors have a variety of learning styles and some who have very active styles of learning in terms of their desire to acquire knowledge do not wish to use such a system, often perceiving it as time wasting or not fitting their needs.

얼마나 오래 사용하나요? How long do people use portfolios for?

One of the most interesting phenomena of portfolio use amongst GP registrars is the bridging phenomenon (Snadden & Thomas, 1998). The transition from working in the fairly sheltered environment of hospital to the culture of uncertainty and isolation that is general practice is not easy. Portfolios assist in the transition by capturing and supporting the young doctor’s difficulties in adapting to a complex and changing environment.

포트폴리오를 쓰면 도움이 된다고 느끼나요? Do people feel they have benefited from keeping a portfolio?

For those that keep portfolios there are several benefits. They help focus teaching sessions on material that is

relevant to them.

In addition to this they help track learning by keeping a record of what the learner has achieved. More importantly the learner can examine areas in which he/she is not confident and plan new learning based on these.

Portfolios explore performance in practice and as such they are a challenging, and confidence building, learning mechanism for both learner and teacher.

Conclusion

A well-completed portfolio will give a young doctor or student and his/her teacher a written record of what has been accomplished in a training period.

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Research Article

The use of portfolio learning in medical education

1998, Vol. 20, No. 3 , Pages 192-199 (doi:10.1080/01421599880904)

DAVID SNADDEN MARY THOMAS

SUMMARY Portfolio learning is a method of encouraging adult and reflective learning for professionals. Derived from the graphic arts it is based on developing a collection of evidence that learning has taken place. Portfolios are being used more in nursing and medical education. They are excellent tools for assisting formative assessment and professional development. They are also being developed for formal assessment processes, being seen as one form of authentic assessment particularly suited to evaluating the application of theory in practice. There are, however, difficulties associated with the lack of standardization of the content of portfolios in terms of developing assessment instruments. As long as formal assessment is based on the philosophy of measurement, portfolios will be difficult to assess and will require the development of noncomparative methods of assessment. This article describes some of the history of portfolios, how to develop a portfolio to assist learning or for professional development purposes and discusses some of the current thinking about the use of portfolios for formal assessment.

Read More: http://informahealthcare.com/doi/abs/10.1080/01421599880904