Evolution of the New Pathway Curriculum at Harvard Medical School (1)

Evolution of the New Pathway Curriculum at Harvard Medical School

the new integrated curriculum

---

Jules L. Dienstag

ABSTRACT 

1985년 하버드 의과대학은 "New Pathway"라는 새로운 교육과정을 도입하였다. 이 교과과정은 능동적, 성인학습을 바탕으로 하여 문제중심, 교수촉진 소그룹 교육방식을 통해 평생학습과 자기주도학습을 향상시키기 위해 개발되었다. Basic science 과정에서 임상적으로 관련있는 내용들이 성공적으로 통합되었음에도 불구하고 NP교과과정의 성과는 임상실습 이전의 교과과정에 국한되었다. 게다가 의료가 점차 입원환자에서 외래환자 중심으로 바뀌어가는 상황은 임상교육을 제한하는 요인으로 작용하였고, 임상교육에서 교수들이 전통적인 교수자의 역할을 하는 것도 제한적이 되었다.

In 1985, Harvard Medical School adopted a “New Pathway” curriculum, based on active, adult learning through problem-based, faculty-facilitated small-group tutorials designed to promote lifelong skills of self-directed learning. Despite the successful integration of clinically relevant material in basic science courses, the New Pathway goals were confined primarily to the preclinical years. In addition, the shifting balance in the delivery of health care from inpatient to ambulatory settings limited the richness of clinical education in clinical clerkships, creating obstacles for faculty in their traditional roles as teachers. 

2006년 HMS는 네 가지 원칙에 기반하여 더 통합적인  교과과정을 도입하였다. 네 가지 원칙은 다음과 같다.

In 2006, Harvard Medical School adopted a more integrated curriculum based on four principles that emerged after half a decade of self-reflection and planning: 

(1) 학생의 모든 학습경험에 기초과학/인구과학을 임상의학에 접목시킨다.

(1) integrate the teaching of basic/population science and clinical medicine throughout the entire student experience; 

(2) 교수-학생간 의미있고 집중적인 관계를 재정립하고, 교수의 참여를 높인다.

(2) reestablish meaningful and intensive faculty-student interactions and reengage the faculty; 

(3) 임상교육의 새로운 모델을 개발하여 환자경험에 있어 장기적 연속성을 가질 수 있게 하고, 학제간 교육과정을 만들고, 교수에 의한 멘토링을 하고, 학생 평가를 한다.

(3) develop a new model of clinical education that offers longitudinal continuity of patient experience, cross-disciplinary curriculum, faculty mentoring, and student evaluation; and 

(4) 모든 학생들이 심화적이면서 교수의 지도를 받는 연구 프로젝트에 참여할 기회를 갖는다.

(4) provide opportunities for all students to pursue an in-depth, faculty-mentored scholarly project.

이 New Integrated Curriculum의 네 가지 원칙은 "학생과 교수가 학문과 리더십을 향한 파트너십을 갖도록 하려는" 우리의 교육과정에 대한 비전을 보여준다.

These principles of our New Integrated Curriculum reflect our vision for a curriculum that fosters a partnership between students and faculty in the pursuit of scholarship and leadership.

Dean for Medical Education, Harvard Medical School, Gordon Hall, Room 103, 25 Shattuck Street, Boston, MA 02115.

E-mail: jules_dienstag@hms.harvard.edu.

Perspectives in Biology and Medicine, volume 54, number 1 (winter 2011):36–54

© 2011 by The Johns Hopkins University Press

---

플렉스너가 20세기 초 의학교육에 관하여 저술했을 때, 그는 의학교육과 의술(의학)은 과학적 방법에 기반해야 하며, 의학교육은 - 학문과 연구의 중심인 - 대학에 속해야 한다고 주장했다.

WHEN FLEXNER WROTE about medical education at the beginning of the 20th century, he articulated and amplified the emerging view that medical education and the practice of medicine should be grounded in scientific method and that medical education belonged in the province of the university, an environment dedicated to original scholarship and investigation (Cooke et al. 2006; Flexner 1910; Ludmerer 2010).

그러나 대부분의 20세기동안 플렉스너의 교리는 소위 "2+2 교육과정"으로 드러난게 고작이었다.

For most of the 20th century, however, the Flexner “doctrine” was expressed in a so-called “2 + 2” curriculum split: two years of basic science followed by two years of clinical medicine

1985년, Daniel Tosteson학장이 하버드 의과대학에 "New Pathway in General Medical Education"을 도입하였고, 당시 그는 학생의 능동적 참여와 자율적 학습, 즉 학습의 성인학습자적 접근을 지지하였다.

When then dean Daniel Tosteson championed the “New Pathway in General Medical Education,” a new curriculum introduced in 1985 at Harvard Medical School, he espoused a focus on active engagement by students in their own learning—in other words, adult approaches to learning

비록 첫 2년이 대부분 기초생명과학을 가르치는데 사용되고, 그 다음 2년은 임상의학을 가르치는데 사용되긴 하지만 New Pathway는 직접 임상수기를 실습 전에 익히도록 할 뿐만 아니라 임상내용을 초기에 접하도록 하는 특징이 있었다.

Although the bulk of the first two years was devoted to teaching the basic biological (and population) sciences and the last two years to teaching clinical medicine, the New Pathway was characterized by the early introduction of clinical content as well as hands-on clinical skills in the preclinical years.

NP 교육과정을 도입하는 것은 학교에 큰 변화를 가져왔다. 그러나 20년이 지난 지금 NP의 목표는 주로 첫 2년에 국한되고 있으며, 임상실습을 도는 2년간에는 거의 실현되지 않고 있다.

Adoption of the New Pathway curriculum was transformative for our school (Tosteson et al. 1994), but 20 years later, the consensus was that the New Pathway goals had been confined primarily to the first two years and, generally,were not reinforced or realized during the clinical years.

임상실습 시기에 학습환경 악화(erosion)되는 것은 교수자와 학습자 모두에게 손해였다. 이러한 입원환자 중심의 카오스적 상태로 인해 많은 희생자가 발생하였다. 교수의 가르치는 역할은 선생님/멘토가 아닌 서비스/기질 제공자로 바뀌어있었다. 그 결과로 우리의 많은 유능한 시니어 교수들은 가르치는 것을 점점 멀리하면서 학생에게 영감을 줄 수 있는 영웅으로서의 역할을 더 이상 하지 못하게 되었다. 게다가 임상교육이 각 과별로 분절되고 임상교육의 일관성이 떨어지면서 임상실습은 학생이 하나의 독립된 임상과에서 또 다른 독립된 임상과로 로테이션하는 것이 되었다. 지속적, 장기적 경험을 쌓지 못했고, 관리나 피드백이 없었고, 학문적/전문직업적/개인적 발달은 이루어지지 않았다.

This erosion in the learning environment took a toll on teachers and learners. As a casualty of the chaotic pace of inpatient medicine, the role of teaching faculty shifted from teacher/mentor to service/disposition provider. Consequently, many of our most talented, accomplished senior faculty disengaged from teaching, depriving students of their traditional role models and inspirational heroes. In addition, because of the fragmentation of segmented clerkships and the absence of coherence in clinical education as students rotated from one independent clinical service to another and from one teaching hospital to another, the clerkship experience was not conducive to supporting longitudinal experience, oversight/feedback, and attention to academic, professional, and personal development—important elements of student-centered learning.

2001년부터 LCME의 재인증을 준비하는 동안 자기성찰적 과정을 거치며 우리는 NP교육과정의 한계를 넘어서 이를 더 강화할 수 있도록 하는 다년간의 과정에 착수했다.

Beginning in 2001, with the introspective process of preparing for reaccreditation by the Liaison Committee on Medical Education, we began a multiyear process to consider how we could build upon the strengths of our New Pathway curriculum and address its limitations.

오년간의 여러 과정을 거쳐 교육과정 개혁의 네 가지 핵심 제안이 만들어졌다.

From a five-year series of blue-sky committees, task forces, and working groups involving hundreds of faculty and student representatives emerged four overarching recommendations for curriculum reform: 

(1) increase the rigor of the teaching of basic biologic and population sciences and integrate the teaching of science and clinical medicine throughout the entire student experience; 

(2) reestablish meaningful and intensive faculty-student interactions and reengage the faculty, including the most senior faculty, in the education mission, as teachers, mentors, and guides; 

(3) develop a new model of clinical education that is based on the educational and developmental needs of the student and that offers longitudinal continuity of patient experience, cross-disciplinary curricular content, faculty mentoring, and student evaluation; and 

(4) provide opportunities for all medical students to model the experience of discovery by pursuing in-depth scholarship in one area of inquiry and producing a written scholarly product under the guidance of, and in partnership with, an expert faculty member. 

또한 교육과정 개선 과정에서 교수법과 교육환경을 바로잡고, 인도주의/전문직업성/다문화적 감수성/의사소통능력을 강화하는 것에도 뜻을 모았다.

Also included in a consensus on curriculum reform was a commitment to optimize pedagogic methods and teaching environments and to emphasize and nurture humanism, professionalism, and cross-cultural sensitivity and communication skills (HMS 2004).

Introduction to the Profession

교육과정은 2주짜리 도입부 교과과정으로 시작한다. 다양한 관점에서 직업에 대한 넓은 시야를 갖도록 해주는 역할 등.

The curriculum begins with a two-week introductory course designed 

to provide a broad overview of the profession from a variety of perspectives; 

to introduce students to problem-based, collaborative learning; and 

to clarify the goals, expectations, and demands placed upon students as they make the transition to physicians-in-training and prepare to undergo a profound change in identity and world view. 

비록 전달하고자 하는 메시지가 이 때에는 와닿지 않을 지 모르지만, 이 과정의 주요한 목적 중 하나는 학생들이 학습과정에서 개개인의 책임을 느낄 수 있도록 하는 것이고, 학생들이 배워야 하는 것은 시험에 통과하기 위해서가 아니라 환자에 대한 의무를 다하고 환자에게 기여할 수 있는 최고의 의사가 되기 위한 것임을 아는 것이다.

Although the message may not penetrate this early in medical education, one of the objectives of the course is to help students begin to assume personal responsibility in the learning process, to abandon the mindset of learning what they need to know to pass a test in favor of thinking about medical education as preparation for becoming the best physician for—contributing and fulfilling their responsibility to—their patients.

Fundamentals of Medicine

임상실습 전 교육과정에서 계속 강조되는 것은 교과목간 통합이다. 

Emphasized in all components (basic science, clinical-introductory, population science) of the preclinical curriculum is content integration within and across courses.

첫 해에는 분자에서 세포로, 그리고 기관으로 가도록 설계되어있다.

The first-year curriculum is designed to build from molecules to cells to organisms, beginning with a molecular framework (biochemistry/molecular biology/cell biology) that integrates seamlessly with the transition to anatomy. 

두 번째 해에는 약리학, 병리학, 영양학 등이 통합된 형태로 병태생리학을 배운다.

In the second year, the teaching of pathophysiology is presented in an integrated way that incorporates aspects of pharmacology, pathology, and nutrition associated with individual systems. 

또한 인구과학과 의료윤리, 전문직업성, 사회의학, 임상역학 등이 포함된다.

In addition, a sequence of courses in the population sciences,which addresses important issues confronting physicians in the 21st century and which underlie contemporary medicine—medical ethics and professionalism, social medicine, clinical epidemiology and population health (Finkelstein et al. 2008), and health policy—are integrated with the teaching of the basic biological sciences and with introductory clinical exposures

Principal Clinical Experience

새로운 교육과정에서 가장 중요한 것은 임상 교육과정을 재구조화 하는 것이다. 전통적으로 3학년 때 필수 임상실습을 하게 된다. 분절화와 교육학적 연속성이 떨어지는 한계를 극복하고, 학생이 소외되는 것을 해소하기 위해서 2학년 5월부터 시작되어 한 병원에서 전체 핵심임상과를 포괄하는 48주짜리 장기프로그램을 도입하였다. 

An important centerpiece element of the new curriculum—the most tangible component of our curriculum reform initiative—is the restructuring of the clinical curriculum, which, traditionally, comprised the third-year core clinical clerkships.To overcome the fragmentation and absence of pedagogical continuity of core clerkship experiences and the marginalization of students on clinical services during the core clinical clerkships, we adopted an integrated 48-week long program beginning in May of the second year and incorporating all the disciplines of the core clinical clerkships (medicine, surgery, obstetrics/gynecology, pediatrics, neurology, psychiatry, radiology, and primary care) at one hospital site. The seed for this program was planted at Cambridge Hospital, a 118-bed community teaching hospital, in a pilot program beginning in 2004.

더 큰 병원(BIDMC, BWH, MGH)에서는 특정 임상과에 대한 집중적 노출 기회를 유지하도록 discrete immersion clerkship을 하였다. 48주짜리 프로그램(PCE)에 핵심 임상과 실습을 통합한 것이었다.

At our larger teaching hospitals—Beth Israel Deaconess Medical Center (BIDMC; Bell et al. 2008), Brigham andWomen’s Hospital (BWH), and Massachusetts General Hospital (MGH)—the pioneering elements of the Cambridge Integrated Clerkship were integrated with discrete immersion clerkships, which were preserved to provide an intense exposure to discipline-specific approaches to patient care.This 48-week program, the Principal Clinical Experience (PCE), is an integrated approach to the core clinical disciplines. In the PCE, students remain predominantly at one hospital site for all their discrete disciplinary clinical clerkships, instead of rotating from hospital to hospital, as had been done in the past.

접근법은 환자중심이고 학생중심 학습이었다. 따라서 학생들은 환자, 교수들과 더 많은 접촉을 하게 된다. 각 학생들이 어떻게 향상되는 것은 가까이 관찰하여 교정이 필요한 부족한 부분을 빨리 찾아낸다.

The approach is patient-centered and focuses on student-centered learning; accordingly, students have more contact with their patients and with their faculty. Each student’s progress is monitored closely, allowing for early detection of weaknesses in need of remediation and strengths that would benefit from reinforcement. Another important objective for the PCE is student-centered clinical learning that is uncoupled from internship preparation/auditioning.

요약하면, 학생들은 PCE site에서 실습을 하고, 교수들은 그들의 PCE학생에 대한 ownership을 갖는다. 추가적으로 학생들은 동료끼리 학습집단을 형성하여 서로 돕고, PCE는 편안한 학습환경을 만들어준다.

In short, students identified with their PCE sites, and the faculty took ownership of their PCE students. In addition, students formed a learning community with peer-group support, and the PCE provided a comfortable learning environment that fostered opportunities to create connections with faculty and staff. Faculty appreciated the opportunity to work across disciplines, the ability to get to know students well, and the ability to assist in student growth and development.

Advanced Experiences in Clinical Medicine and Basic Science

의과대학 4학년는 가장 구조화가 덜 되어있는 시기이다. 학습목표를 강화하고 임상 세팅에 대한 자신감과 익숙함을 향상시키기 위해서 4학년은 의학교육의 '발효' 시기와도 같으며, 자기성찰의 시기이고, 미래에 학문(진로)를 선택하거나 강화하는 시기이다.

The fourth year of medical school, the elective year, has been the least structured of the medical school experiences.As an important time to consolidate learning objectives and to increase familiarity with and confidence in clinical settings, the fourth year provides leavening to a medical education, a period of reflection, and an opportunity to select or reinforce the selection of a future discipline.

이번 의학교육 개혁을 할 때 4학년 과정에 대해서 고려했던 것은 의과대학의 마지막 학년은 느슨하게 구성되어서 중앙의 감독/지시/엄격한 관심을 줄이도록 해야 한다는 것이었다.

When we considered the fourth year during our medical education reform  initiative, our collective consensus was that the final year of medical school was organized very loosely with limited central oversight, guidance, or attention to rigor.

대부분의 변화들은 더 많은 자원, 새로운 교과목, 창의적 혁신이 필요했지만 그 어떤 것도 금방 달성되는 것은 아니었다. 되돌아보면 우리는 1학년과 2학년을 응축시키고, 더 견고하게 조직된 48주 PCE를 도입하고, 연구프로젝트를 야심차게 더하였는데, subinternship을 하나 더 추가한 것은 4년 교육과정에 들어가기에는 너무 과도해서 외과 subinternship은 권고되지만 의무는 아니게 하였다.

Many of the recommended changes will require more resources, new courses, and creative innovation, all of which cannot be achieved quickly. In retrospect, we realize that condensing Years I and II (Fundamentals of Medicine), launching a rigidly structured, 48-week Principal Clinical Experience, and adding a required scholarly project is an ambitious program, and that adding yet another subinternship was just too much to fit into a four-year curriculum a surgical subinternship will be recommended but not required.

In-Depth Educational Experience

하버드 의과대학에서 의학교육 개혁의 네 번째 원칙은 MD프로그램의 한 부분으로서 교수가 멘토를 하고 학문적으로 심화된 경험을 하는 것이었다.

The fourth principle of medical education reform at Harvard Medical School was to require, as part of the MD program, a mentored, scholarly, in-depth experience that would culminate in a substantive written product.

"Scholarship in Medicine Program"의 목적은 모든 학생을 연구자로 만드는 것이 아니라, Thesis든 다른 어떤 형태든, 문제를 찾고, 교수와 함께 그 문제를 해결하고, 자신이 한 일을 성찰하는 경험을 해보도록 하는 것이었다.

The objective of the “Scholarship in Medicine Program” is not to turn all our students into research investigators, but instead to model for them an experience in which they will identify a problem, work with a faculty member to address that problem, and prepare a reflective written summary of the work, either as a formal thesis or as a less formal written report

학생이 연구자의 길을 택하든 그렇지 않든, 그들은 궁극적으로 해결해야만 하는 문제에 맞닥뜨리게 될 것이다. 우리가 바라는 것은 학생들이 그러한 문제를 해결할 수 있는 능력을 갖추게 하기 위해서 그러한 종류의 실제 경험을 하도록 하는 것이다.

Whether or not students will pursue a formal investigative career, they will all encounter problems that beg for solutions.Our aspiration is for students to realize they are capable of tackling such problems and to provide them with a concrete experience in having addressed such a problem.

이것의 기본 개념은 답이 없는 문제를 어떻게 해결해야 하는가에 대해서 경험하는 것이고, 그 목표는 리더십의 근본이라 할 수 있는 깊은 성찰이 가능한 졸업생을 키우는 것이다.

The concept is to help them appreciate and experience how to address unanswered questions, and the objective is to generate graduates capable of deep reflection, which is at the heart of leadership.

이러한 연구프로젝트를 도입하는 것은 더 많은 교수들이 교육에 참여하게 하고, 교수-학생 파트너십을 강화하며, 의학교육 개혁 이니셔티브의 또 다른 핵심 중 하나인 교수들의 교육참여를 높이는 것에 기여하게 된다. 우리는 또한 학생과 교수 모두에게 의학교육은 정보 목록을 나열하여 제공하는 것이 아니라 교수자와 학습자가 '알려진 것'과 '알려지지 않은 것'사이의 경계를 확장시키기 위해 적극적으로 참여하는 것이라는 메시지를 전달하고자 했다.

Adoption of such a scholarly project requirement also draws more faculty into teaching and sustains faculty-student partnerships, thereby fulfilling one of the other pillars of our medical education reform initiative—to engage the faculty in the education of medical students.We also send the message to both faculty and students that medical education should not be designed to catalogue information but to encourage teachers and learners to participate actively in extending the boundary between what is known and what is unknown.

인문대학과 사회대학의 교수들은 학문 탐구의 정수를 다음과 같이 표현했다. "학생들에게 '알려진 것'의 경계를 확장시키고, 새로운 발견을 하는 희열을 경험하게 하고, 전혀 기대하지 않았던 것을 만들어내는 것으로부터오는 성취감을 맛볼 수 있게 하는 것이다"

University Faculty of Arts and Sciences, captured the essence of scholarly inquiry:“the ability to bring students into the process of pushing bounds of what is known—to experience the thrill of a new discovery, and to feel the sense of accomplishment that comes from creating something really unexpected.”

---

Perspect Biol Med. 2011 Winter;54(1):36-54. doi: 10.1353/pbm.2011.0003.

Evolution of the New Pathway curriculum at Harvard Medical School: the new integrated curriculum.

Dienstag JL.

Author information

Abstract

In 1985, Harvard Medical School adopted a "New Pathway" curriculum, based on active, adult learning through problem-based, faculty-facilitated small-group tutorials designed to promote lifelong skills of self-directed learning. Despite the successful integration of clinically relevant material in basic science courses, the New Pathway goals were confined primarily to the preclinical years. In addition, the shifting balance in the delivery of health care from inpatient to ambulatory settings limited the richness of clinical education in clinical clerkships, creating obstacles for faculty in their traditional roles as teachers. In 2006, Harvard Medical School adopted a more integrated curriculum based on four principles that emerged after half a decade of self-reflection and planning: (1) integrate the teaching of basic/population science and clinical medicine throughout the entire student experience; (2) reestablish meaningful and intensive faculty-student interactions and reengage the faculty; (3) develop a new model of clinical education that offers longitudinal continuity of patient experience, cross-disciplinary curriculum, faculty mentoring, and student evaluation; and (4) provide opportunities for all students to pursue an in-depth, faculty-mentored scholarly project. These principles of our New Integrated Curriculumreflect our vision for a curriculum that fosters a partnership between students and faculty in the pursuit of scholarship and leadership.

PMID:

 

21399382

 

[PubMed - indexed for MEDLINE]