임상교육 구조 개혁의 핵심 원칙 - "연속성"

“Continuity” as an Organizing Principle for Clinical Education Reform

David A. Hirsh, M.D., Barbara Ogur, M.D., George E. Thibault, M.D., and Malcolm Cox, M.D.

의학교육의 궁극적인 목적 - 건강에 대한 사회적 요구 달성 - 을 위해서 학부의학교육은 모든 의학 분야를 망라하여 핵심역량에 대하여 폭넓게 숙련된 학생을 양성하는 것이다. 고도로 전문화되고 생산성을 높일 것이 요구되어 교육이 한정된 자원을 놓고 연구와 진료와 같은 다른 영역과 경쟁을 해야 하는 환경에서 어떻게 이 목표를 달성할 것인지는 중요한 도전과제라 할 수 있다.

If the ultimate purpose of medical education —to meet the health needs of society — is to be achieved, the primary goal of undergraduate medical education should be to produce students who are broadly skilled in the core competencies that transcend all disciplines of medicine.1,2 The challenge is how to accomplish this goal in a clinical learning environment fragmented by increasing specialization and demands for clinical productivity and constrained by a prevailing culture in which education must compete with research and clinical practice for medical school resources.3

의과학과 진료의 발전은 눈부신데, 미국 의과대학의 임상교육 모델은 William Osler가 살던 백년 전과 비교했을 때 거의 달라진게 없다. 학생들은 급성기 병원의 특정 전공과에 배치되어 랜덤한 순서로 짧은 로테이션을 돌게 된다. 그리고 그 속에서 학생이 겪게 되는 임상경험역시 Osler의 시대와 다를게 별로 없다.

As compared with the dramatic changes that have occurred in biomedical science and the practice of medicine, the fundamental model of clinical education in American medical schools has changed little since the time of Sir William Osler, a century ago. Students are still assigned to specialty-specific teams of interns, residents, and supervising faculty physicians for relatively brief, randomly sequenced rotations in acute care hospitals. 4,5 And the core clinical credentialing experience continues to be this same series of rotations, primarily in the third year of the traditional four-year undergraduate curriculum, just as it was in Osler’s day.

학생들은 졸업 후 수련과정에서 최소 3년, 길게는 8년 이상을 병원에서 보내게 될 것이며, 이 시기에 필요한 기술들을 연마하기에 병원이라는 환경이 학습 기회를 제공하는 측면에서는 부족함이 없으나, 현재의 모델은 미래사회의 요구와 변화를 전혀 따라가지 못하고 있다. 이를 인지한 많은 사람들은 현재의 급성기 임상교육 모델의 강점을 유지하면서, 현 모델이 가진 주요한 한계점인 '서로 다른 학습경험 사이의 연계성과 연속성'을 극복하기 위한 임상교육의 새로운 모델을 요구하기에 나섰다.

Although there is no doubt that the hospital environment remains rich in learning opportunities for medical students and that students need to learn the skills necessary to succeed in an environment in which most of them will spend 3 to 8 years of postgraduate training, there is a growing sense nationally that the current model is poorly aligned with society’s present and future health care needs.6,7 This realization has led many observers to call for a new model of clinical education, one that would incorporate the strengths of the present acute care educational model but eliminate the model’s major weakness — a lack of connection or continuity among different learning experiences.8,9

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교육적 연속성

educational continuity

수련중인 의사에게 있어서, 근대 학습 이론에 기반을 둔 '교육의 연속성'이란, 전문직으로서 그리고 한 개인으로서 지속적인 발전에 대한 것이기도 하다. 교육과정의 한 부분이 아니라, 전체 교육과정에 대한 'ownership'을 갖는 것이 '교육적 연속성'의 필수조건이라고 할 수 있다.

Rooted in the principles of modern learning theory,10,11 the notion of educational continuity reflects the progressive professional and personal development required of physicians in training.12 A spirit of “ownership” of the entire curriculum, rather than one discipline-specific portion of the curriculum, is a prerequisite for educational continuity.13

Continuity of Care

언제나 가장 강력한 동기유발요인은 환자에게 헌신하는 마음가짐이었다. 봉사학습(service learning programs)에서는 학생들이 자신의 열망을 이룰 수 있게 하는 것이 가장 강력하게 학습을 지지하는 것이었으나, 임상실습경험 그 자체에서는 막상 이것을 거의 활용하지 않고 있었다.

Throughout the history of the profession, the most powerful motivator for learning has been the sense of deep commitment to patients. Connecting the student’s desire to serve with his or her desire to learn has strong support in learning theory and has been used effectively for many years in a wide variety of service learning programs in health-related disciplines. However, only rarely has service learning been part of the core clerkship experience itself.14

Continuity of Curriculum

학습자의 가치관/태도/지식/술기 등이 향상되도록 하기 위해서는, 교육과정의 각 요소들이 서로 논리적인 연결구조를 가지고 있어야 한다. 이러한 교육과정의 특징은 세 가지로 요약할 수 있다.

To support the progression of a learner’s values, attitudes, knowledge, and skills, each component of a curriculum should have a rational, considered relationship with all others. A developmentally progressive curriculum has three major aspects. 

First, there is a rational sequential order that facilitates learning, with certain types of knowledge and skills serving as the foundation for subsequent learning. Skills that are notably different, but equally complex, may still be most appropriately taught in a particular order. For example, knowledge of anatomy and pathophysiology facilitates the taking of a medical history. 

Second, more complex tasks should follow some degree of achievement in the performance of more simple but related tasks. Thus, one learns to construct a simple problem list before learning to develop a complicated differential diagnosis. Similarly, grappling with complex therapeutic decisions makes little sense for a student who has yet to master rudimentary diagnostic decision making. 

Third, the curriculum should be implemented in a learner-centered manner, such that a given student’s learning is tailored to his or her particular evolving (i.e., developmentally appropriate) needs.

Continuity of Supervision

교수와 학생간, 그리고 여러 교수들간 연계성을 확립하는 것이 중요하다. 학생들은 지속적으로 지도를 해주는 사람에 대해 환자진료에 대해서 공동의 책임을 갖는다는 직업적인 친밀감을 갖게 된다. 

Establishing connections between faculty, other caregivers, and students and among faculty across disciplines is critical to forming a productive learning community.16 Students and longitudinal preceptors share the professional intimacy of dual responsibility for patient care. Such relationships in which faculty members have personal responsibility for overseeing their own students, provide students with the emotional comfort to take intellectual risks in their learning. At the same time, trusting relationships and shared goals foster coaching, promote effective feedback, and enhance clinical performance.

장애물

barriers to educational continuity

'교육적 연속성'의 개념이 임상교육 개혁에 있어서 핵심 원칙이긴 하지만, 그 장애물 또한 만만치 않다. 

Although the concept of educational continuity provides a powerful organizing principle for clinical education reform, the barriers to changing the manner in which the traditional core clinical clerkship experience is organized should not be underestimated (Table 2). Promoting innovation on the basis of either educational theory or nascent outcomes data alone will require visionary leadership, innovative resource management, and careful attention to learning, cultural, and regulatory issues.

새로운 모델

new models of clinical clerkships

A부터 I까지 각각의 모델과 예시에 대한 설명

Promoting educational continuity is complicated by the traditional division of the core clinical clerkship experience into a disconnected series of independently governed, discipline-specific, randomly ordered, sequential blocks (Fig. 1A), each characterized by largely ad hoc patient assignments and poorly coordinated learning objectives. To provide opportunities for a more collective approach to curriculum design and management and to better deal with so-called orphan topics, medical schools have begun to assume more centralized control of the clerkship year. Over the past decade, this shift in governance has allowed for the development of a variety of new models of clinical clerkships, many of which have incorporated elements of educational continuity into the overall learning experience. 

Some schools have developed interdisciplinary “intersessions” or “interclerkships” (courses, generally of about a week’s duration, interposed between sequential clerkships) (Fig. 1B)19 and longitudinal “themes” or “threads” (courses that link similar content between clerkships) (Fig. 1C).20 Both models provide opportunities for interdisciplinary curriculum design and management. However, short of major curricular revisions (such as consolidating core clerkship objectives or extending the duration of the overall experience), time limitations curtail the ability of either approach to reach its full potential. Many of these new clerkship experiences have used small-group, problem-based learning, which although a natural locus for interdisciplinary teaching,21 had not previously been used in the clinical curriculum as commonly as in the preclinical curriculum.22 

예시) In England, at the University of Manchester, modules of thematically organized, problem-based material are now being taught alongside traditional discipline-specific “attachments” (clerkships).23 Semistructured interviews of Manchester graduates have indicated significant gains in dealing with clinical uncertainty, knowing their personal limits, and asking for help when these limits are exceeded.24 

예시) A variant of problem-based learning has been used at the University of Dundee in Scotland to integrate content across the entire curriculum.25 Task-based learning uses the clinical experience itself, rather than “paper” cases, to generate examples of a series of predetermined tasks, with the students themselves responsible for finding opportunities to explore these tasks as they move through a discipline-specific, sequential curriculum. Task-based learning is credited with enhancing the transfer of basic science knowledge to the clinical years as well as providing an opportunity for integration of core content across clinical disciplines without the need to create interdisciplinary teaching teams.26

Where curricular content sufficiently overlaps disciplines (neurology and psychiatry or obstetrics and neonatology, for example), the opportunity exists to integrate clerkships more fully across disciplinary lines (Fig. 1D). However, although there are examples of integration in which related clerkships have been grouped together for administrative or scheduling purposes, multidisciplinary governance and joint teaching have been attempted only infrequently and have proved difficult to sustain in a subspecialty-dominant practice environment.27-29

Ambulatory care clerkships are another potential locus for interdisciplinary design and management. In recent years, block or longitudinal ambulatory care clerkships (Fig. 1E and 1F, respectively) — individually or collectively organized by departments of family medicine, general internal medicine, and general pediatrics — have become relatively common components of the core clerkship year.30-34 Although single or isolated block experiences are an appropriate forum for the follow-up of time-limited disorders, they provide little opportunity for exposure to chronic disease management, a major required competency in the modern practice environment. 

Students appear to benefit from longitudinal ambulatory care experiences by developing more effective relationships with patients, gaining insight into the psychosocial aspects of care, and understanding the longitudinal management of chronic illness.35 However, this potential is often degraded by competing inpatient responsibilities and patient-scheduling problems. Recurring ambulatory- block rotations devoted exclusively to generalist community practice, alternating with discipline-specific inpatient blocks (Fig. 1G), might provide an effective solution. Combining both departmentally based and interdisciplinary governance models, this intriguing approach — recently suggested to promote continuity in internal medicine residency education36 — has yet to be tested. Applied to undergraduate education, however, it would probably require substantial lengthening of the traditional clerkship year. 

Many permutations of these basic models are possible. Any substantial combination of sequential and longitudinal experiences — so-called mixed models — would allow for some degree of both discipline-specific immersion and educational continuity (Fig. 1H). 

예시) In a pilot program at Case Western Reserve University in Cleveland, for example, time was equally divided between traditional, discipline-specific inpatient rotations and ambulatory settings, with ambulatory training being provided in specialty clinics and a yearlong continuity experience in one of the generalist disciplines.37 Weekly tutorials and seminars, organized as longitudinal themes and provided by a constant group of faculty mentors, served to bridge individual specialty-specific experiences. Grade distributions in core clerkships were similar, except in psychiatry, in which students in the integrated track achieved significantly higher scores than did students in the traditional curriculum. They also performed better on a generalist Objective Structured Clinical Examination but had a lower mean score on the National Board of Medical Examiners’ internal-medicine “shelf” exam. A majority of students reported that they would choose the integrated third year again and would recommend it to others. 

예시) Similar approaches are being tested at several teaching hospitals associated with Harvard Medical School and the University of California, San Francisco, as part of school-wide efforts on medical education reform. 

Longitudinal organization of most or all specialties that are commonly represented in the core clerkships (Fig. 1I) is an emerging but still uncommon model. 

예시) Motivated by the need for graduates who are interested in practicing in medically underserved areas, some schools have created clerkships that place students in longitudinal ambulatory care experiences — including primary care and multidisciplinary group practices — for a significant portion of their clinical training. When measured against regional workforce goals, these programs have been judged to be quite successful. 38-43 Students in these variously integrated longitudinal clerkships have performed as well as their more traditionally trained counterparts on local and national examinations of clinical competence.44-46

예시) Other schools are testing the feasibility of multidisciplinary, cross-site longitudinal integration without emphasizing primary care or attempting to steer students toward the generalist disciplines. In a pilot project at Harvard Medical School and the Cambridge Health Alliance in Cambridge, Massachusetts, students spend the entire third year learning from serial contact with a carefully selected cohort of patients recruited from their preceptors’ practices in internal medicine, pediatrics, psychiatry, neurology, and obstetrics and gynecology.47 Each patient is followed across all venues of care, including outpatient specialty and subspecialty clinics, the inpatient setting, and rehabilitative, nursing home, and home care. Special arrangements facilitate exposure to patients in the emergency department and a full spectrum of general surgical care. Weekly case-based tutorials on fundamental topics that seek to integrate basic and clinical science, simulation exercises, electronic records, and mentored educational portfolios further emphasize the interdisciplinary and personalized nature of the curriculum.48,49

결론

conclusions

새로운 임상실습 모델이 지속될 가치가 있는지 아니면 또 다른 모델이 등장할 것인지는 두고 볼 일이다. 그러나 모델이 무엇이든 임상교육 환경은 좀 더 전문가로서의 발달을 강조하고 환자 중심의 학습을 받아들어야 할 필요가 있다. 보건의료의 궁극적인 목적이 환자중심의 진료와 의료의 질 향상인 것처럼, 교육시스템에서는 학습자중심의 교육과 교육의 질 향상이 그 핵심이라 할 것이다.

Only time will tell whether any of these new clerkship models will have enduring value or whether yet others will need to emerge. Whatever the model, the clinical environment must be made more receptive to professional development, and learning must be embedded in caring for patients. Just as patient-centeredness and improvements in health care quality are becoming the overarching metrics of the health care delivery system, so too should learner-centeredness and improvements in educational quality become the proximate metrics of the medical education system.

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N Engl J Med. 2007 Feb 22;356(8):858-66.

"Continuity" as an organizing principle for clinical education reform.

Hirsh DA1, Ogur B, Thibault GE, Cox M.

Author information

Comment in

• Educational continuity in clinical clerkships. [N Engl J Med. 2007]
• Continuity in clinical education. [N Engl J Med. 2007]
• Continuity in clinical education. [N Engl J Med. 2007]