“Genes to Society” (유전자에서 사회로) - 존스홉킨스의과대학의 새 교육과정의 논리와 절차(2)

“Genes to Society”—The Logic and Process of the New Curriculum for the Johns Hopkins University School of Medicine

Charles M. Wiener, MD, Patricia A. Thomas, MD, Elizabeth Goodspeed, MHS, David Valle, MD, and David G. Nichols, MD

Abstract

2009년 8월, 존스홉킨스 의과대학은 "유전자에서 사회로"라는 새로운 교육과정을 도입하였다. 새로운 교육과정은 건강과 질병의 맥락을 더 넓은 범위에서 바라보고, 학생들로 하여금 환자의 건강을 더 넓은, 사회/문화/정신/환경이 통합된 시스템에서 바라보도록 하는 것에 그 목적이 있다. 이러한 접근법은 환자의 표현형은 내적인 요인들과 외적인 요인들이 종합되어 나타난다는 것을 보여준다. GTS는 건강과 질병의 이분법적 접근을 거부하고, 환자를 "무증상이며 잠재적인"상태에서 "심각한 상태"까지의 연속체로 바라보도록 한다. GTS는 개인을 유전체에서 환경까지를 포괄하여 바라보는 다가오는 의학의 혁명에 발맞추어 학생들의 경험을 재조직할 필요에 의해 개발되었다. 본 논문은 목표를 설정하고, 새로운 교육과정을 개발하고, 새로운 교육건물을 만들고, 학생 생활과 교수 개발을 향상시키는 5년간의 과정을 묘사하고자 하였다.  수직적 구조와 수평적 구조를 만들었으며, 이 모든 것이 모여 GTS 교육과정을 이루었다. GTS를 도입하는 과정에서 중요한 난관들을 해결하는데 핵심적 요소들은 리더십의 지원, 교수와의 대화, 다양한 구성원의 참여, 좁은 시야의 극복, 개념과 방법을 시험하기 위한 파일럿 코스 등등이었다. GTS는 미래 의사들의 기초과학/임상 진로개발을 위한 토대이다.

In August 2009, the Johns Hopkins University School of Medicine implemented a new curriculum, “Genes to Society” (GTS), aimed at reframing the context of health and illness more broadly, to encourage students to explore the biologic properties of a patient’s health within a larger, integrated system including social, cultural, psychological, and environmental variables. This approach presents the patient’s phenotype as the sum of internal (genes, molecules, cells, and organs) and external (environment, family, and society) factors within a defined system. Unique genotypic and societal factors bring individuality and variability to the student’s attention. GTS rejects the phenotypic dichotomy of health and illness, preferring to view patients along a phenotypic continuum from “asymptomatic and latent” to “critically ill.” GTS grew out of a perceived need to reformulate the student experience to meet the oncoming revolution in medicine that recognizes individuality from the genome to the environment. This article describes the five-year planning process that included the definition of objectives, development of the new curriculum, commission of a new education building, addition of enhancements in student life and faculty development, and creation of a vertical and horizontal structure, all of which culminated in the GTS curriculum. Critical ingredients in meeting the challenges of implementing GTS were leadership support, dialogue with faculty, broad engagement of the institutional community, avoidance of tunnel vision, and the use of pilot courses to test concepts and methods. GTS can be viewed as the foundation for the scientific and clinical career development of future physicians. 

Acad Med. 2010; 85:498–506.

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GTS교육과정 - 구조와 내용

The GTS Curriculum—Structure and Content

GTS교육과정은 2009년 8월 시작되었다.

The GTS curriculum began in August 2009 with a firm grounding in basic science (Chart 1).

처음 네 달의 목적은 학생들에게 의학이 자연/인문/사회과학과 상호작용하는 것임을 깨우쳐주기 위함이다.

A goal of this initial four-month period that includes the SFM, CF, and FPH courses is to heighten students’ awareness of the interaction of the natural, humanistic, and social sciences with medicine.

첫 세 개의 Foundation course를 마치고 나서 학생들은 15개월의 GTS과정을 밟게 된다.

After completion of the three foundations courses—or at a point roughly four months into year one—the students will begin a 15-month course designated the GTS course. This course will be organized by organ system, with each section of the course considered as a continuum from genes and biological systems through to the social and cultural factors that influence health (Chart 1).

GTS기간동안 각각의 기관-시스템 섹션은 핵심개념을 중심으로 분자과학부터 생물학적 시스템, 공공보건까지를 포괄하게 된다.

It is important that, throughout the GTS course, each organ-system section cover relevant core concepts extending from molecular science through biologic systems and public health.

GTS과정동안 학생들은 LAC에서 다양한 임상문제를 접하게 된다.

While they are taking the GTS course, the students will be exposed to a wide range of clinical problems in their Longitudinal Ambulatory Clerkship (LAC), which meets for half-a-day a week from the middle of the first year through most of the second year. The direct clinical and scientific exposures provided by the LAC and the GTS course will allow each of these experiences to highlight the relevance of the other to medicine.

8회의 1주 intersession이 있어서 임상의학과 기초과학의 시너지를 다시 한 번 강조하게 된다.

A second strategy for emphasizing and exploiting synergies between clinical medicine and basic science involves a series of eight 1-week intersessions, interspersed throughout the GTS course in years one and two, that use clinical themes (e.g., patient safety, pain management, and health care disparities) to explore scientific content and social consequences (including safety, cost, ethics, and policy).

SC는 일련의 세미나 과정으로서 학생은 이 시기에 GTS교육과정의 특정 요소에 대해서 연구를 하게 된다.

Scholarly Concentration (SC) series of seminars and mentored scholarship opportunities. The SC course allows the student to explore research in one specific element of the GTS continuum under the guidance of a faculty researcher

SC를 마치기 위해서는 각 학생들은 scholarly project를 제출해야 한다.

To complete the SC course, each student must submit a mentored scholarly project.

GTS교육과정을 마친 후, PBL 모듈과 통합된 4주의 Transition to the Wards 과정이 있다.

After completing the GTS course and a four-week Transition to the Wards course that combines problem-based learning modules with practical information (e.g., interpretation of electrocardiograms, teamwork skills, and image interpretation), the students will embark on clinical clerkships that provide intense clinical experiences building on the CF course in year one and the LAC in years one and two.

핵심 임상 실습이 끝난 뒤에는 Translational Medicine Intersession이 있어서, 기초의학교수와 임상의학교수가 합동으로 임상문제에 대한 기초과학적 함의를 다루는 세미나가 열린다.

After the Core Clinical Clerkships come the weeklong translational medicine intersessions, in which basic science and clinical faculty will jointly lead seminars focusing on the basic science implications of the clinical experiences that the students observed firsthand during their clerkships. In addition to emphasizing the scientific basis of medicine, these intersessions will reinforce rigorous thinking, lifelong learning, and the conceptual basis for patient individuality.

핵심 임상 실습 외에도 학생들은 선택 임상 실습을 하면서 전공의 과정을 준비해야 한다.

In addition to Core Clinical Clerkships, students will continue to have great flexibility to determine their elective rotations to prepare for residency. However, each student also must take an Advanced Clerkship in Chronic Care (e.g., geriatrics, physical medicine and rehabilitation, or palliative care) and an Advanced Clerkship in Intensive Care.

GTS의 사회적 요소들은 개인 환자의 표현형이 가족과 사회에 어떻게 영향을 주는지 (그 반대도 마찬가지)를 배우게 된디ㅏ.

This emphasis on the societal component of GTS within these subinternships illustrates for the student how the individual patient phenotype may affect the family (or community or society), and vice versa.

마지막으로 졸업 전에 capstone course를 밟게 된다.

Finally, just before graduation, all students will complete a capstone course, called Transition to Residency and Preparation for Life (TRIPLE).

GTS교육과정의 중요한 측면은 지속적 발전과 교육적 연속성에 대한 것이다.

Key aspects of the GTS curriculum are its developmental progression and educational continuity.27

우리는 강력한 중심적(비 학과적) 교육과정을 만들어서 수직적, 수평적 요소들을 점검하고 학과 중심으로 되어있던 전통적 교과목 구조를 바꾸었다.

We have established a strong central (nondepartmental) curriculum administration to monitor the vertical and horizontal content areas of the curriculum and to replace the traditional departmental organization of coursework.

GTS교육과정은 무엇이 다른가?

How Will the GTS Curriculum Look Different?

임상 경험이 쌓이면 모든 환자는 서로 다르고 "classical case"라는 것은 교과서 내에만 존재한다는 것을 알게 된다.

Experienced clinicians have learned that every patient is different and that the “classic case” is merely a pedagogical construct.

개개인을 중시하는 GTS는 의학을 바라보는 개념틀을 제시한다.

The GTS perspective, with its emphasis on individuality, provides a conceptual framework for thinking about medicine.

의학지식의 역동성은 intersession동안 강조되고, 핵심 임상 실습이 끝난 뒤 학생들은 일년, 이년 전 GTS기간에 생각했던 주제들에 대해서 자신의 환자경험과 통합시켜서 다시 최신 문헌을 찾아보게 된다.

The dynamic nature of medical knowledge will be reinforced during these intersessions as students revisit, after their Core Clinical Clerkship, topics they considered one to two years earlier in their GTS course, and they will have the opportunity to integrate their background knowledge with firsthand patient experience and review of the current literature.

미래를 향한 도전

Challenges for the Future

교육과정에 대한 전반적 평가가 중요하며, 우리는 현재 정보를 수집하고 있다. 그러나 아직 "GTS교육과정이 이전 것보다 더 좋은지 어떻게 알 수 있나?"라는 질문에 대답할 적절한 metric을 찾지 못하고 있다.

The issue of overall curricular assessment and evaluation is an important challenge. We are currently collecting data on student experience, graduate outcomes, board scores, and career satisfaction that will be used in comparisons with students from the pre-GTS era. However, we do not yet have an adequate metric to answer the often-asked question, “How will we know if the GTS curriculum is better than our old curriculum?”

한가지 가능한 것은 "concept mapping"을 cognitive task analysis로서 사용하도록 하는 것이다.

One potential avenue involves “concept mapping” as a tool for cognitive task analysis.28 Concept mapping is a validated tool of knowledge elicitation and knowledge representation, wherein a team of students could build a relational map of the most relevant concepts in explaining a patient’s phenotype by using GTS concepts.28,29,30 Faculty experts from different specialties could be invited to critique these maps for granularity, comprehensiveness, and relevance to the integration of the knowledge needed for clinical care and communication with the patient. 

위원회는 교육의 가치는 단순히 돈으로 측정되는 것이 아니라, 교육에 대해서 교수들을 인정해주고 승진에 반영하고, 연례 평가에서 학장이 학과 단위로 인정해주는 것이 필요하다고 말했다. 이러한 가치들을 서로 교환할 수 있는 방법을 개발중이다.

This committee noted that valuation of education is measured not only with money but also with faculty recognition and promotion and with departmental recognition during the annual review by the dean. A methodology was developed to interchange these types of valuations— personal, departmental, and financial

교육과정개발동안 일부 자금이 필요한 것은 어쩔 수 없다. 우리는 기존 교과과정을 어설프게 땜질하는 것은 전체를 완전히 바꾸는 것에 비해서 효과가 없을 것이라 생각했다. 동시에 교육을 담당하고 있는 사람들이 꾸준히 자금원을 확장하기 위해서 노력해야 한다.

The need for a certain level of funds is inescapable during curriculum reform. We argue that minor tinkering with an existing curriculum is less likely to be perceived as adding value to an institution than is wholesale reform. At the same time, those responsible for education must constantly strive to diversify the funding base beyond tuition—through grants, consulting contracts, continuing education courses, etc.—while paying scrupulous attention to the risks of conflict of interest or dilution of the institutional mission.

요약

Summary

의과대학의 목표는 바뀌지 않았다. 단지, 이 목표를 달성하기 위해서 미래 세대의 의사들은 새로운 개념적 기반이 필요하다는 것이다. 

The goal of medical school—namely, to educate students in preparation for fulfilling careers in clinical care, investigation, education, and leadership— has not changed; however, to reach this goal, the next generation of physicians will require a new conceptual foundation of health and disease that focuses on individual characteristics and that explores how they interact with accrued environmental experiences. 

Hood 등은 이러한 접근법을 P4 medicine이라 불렀다. P4는 Predictive, Preventive, Personalized, Participatory medicine의 약자이다. 우리의 GTS 교육과정은 P4 medicine을 가르치기 위한 것이다. 최근 Macy재단의 보고서는 의과대학 교육과정이 좀 더 사회적 요구와 기대에 맞추어져야한다고 기술하고 있다.

Hood and colleagues31 called this approach “P4 medicine,” with “P4” representing predictive, preventive, personalized, and participatory medicine. Our GTS curriculum proposes a way of teaching P4 medicine. A recent report from the Macy Foundation proposed that medical school curricula become more aligned with societal needs and expectations.32

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Acad Med. 2010 Mar;85(3):498-506. doi: 10.1097/ACM.0b013e3181ccbebf.

"Genes to society"--the logic and process of the new curriculum for the Johns Hopkins University School of Medicine.

Wiener CM1, Thomas PA, Goodspeed E, Valle D, Nichols DG.

Author information

Abstract

In August 2009, the Johns Hopkins University School of Medicine implemented a new curriculum, "Genes to Society" (GTS), aimed at reframing the context of health and illness more broadly, to encourage students to explore the biologic properties of a patient's health within a larger, integrated system including social, cultural, psychological, and environmental variables. This approach presents the patient's phenotype as the sum of internal (genes, molecules, cells, and organs) and external (environment, family, and society) factors within a defined system. Unique genotypic and societal factors bring individuality and variability to the student's attention. GTS rejects the phenotypic dichotomy of health and illness, preferring to view patients along a phenotypic continuum from "asymptomatic and latent" to "critically ill." GTS grew out of a perceived need to reformulate the student experience to meet the oncoming revolution in medicine that recognizes individuality from the genome to the environment. This article describes the five-year planning process that included the definition of objectives, development of the new curriculum, commission of a new education building, addition of enhancements in student life and faculty development, and creation of a vertical and horizontal structure, all of which culminated in the GTS curriculum. Critical ingredients in meeting the challenges of implementing GTS were leadership support, dialogue with faculty, broad engagement of the institutional community, avoidance of tunnel vision, and the use of pilot courses to test concepts and methods. GTS can be viewed as the foundation for the scientific and clinical career development of future physicians.