일차진료 프로그램에서의 학습 : Maastricht '입양' 프로그램

Learning in a clinical education programme in primary care: the Maastricht Adoption Programme

M Tim Mainhard,1 Marianne M van den Hurk,2,3 Margaretha W J van de Wiel,3 Harry F J M Crebolder4

& Albert J J A Scherpbier5

INTRODUCTION

Maastricht 대학에서는 임상실습 전 의학교육에서 지식, 술기, 태도의 integration을 위하여 Adoption Programme(입양 프로그램, MAP)를 도입하였다. 학생들은 일차진료 세팅에서 주어진 과제를 수행하며, 이 과제에 대한 설명과 토론이 practical medical coaching group에서 이뤄진다. 이 연구의 목적은 프로그램의 학습에 영향을 주는 요소들간의 관계를 보기 위한 것이다.

At Maastricht University, the integration of knowledge, skills and attitudes in preclinical medical education is promoted by an Adoption Programme, where students carry out assignments in a general practice setting. The assignments are explained and discussed in practical medical coaching groups. The aim of this study was to examine the relationships between the elements that affect learning in the programme.

METHOD 

188명의 의과대학생으로부터 받은 설문결과를 사용하여 프로그램의 인과관계 모델을 테스트하였다. action과 reflection on action은 서로 구분을 하였다. 인지된 교육성(perceived instructiveness)를 다음의 변인들과 인과관계 분석을 하였다.

Data from the evaluation questionnaires of 188 medical students were used to test a causal model of learning in the programme. A distinction was made between action and reflection on action. We examined the relationships between perceived instructiveness (the programme’s value as a learning experience) and the following variables: 

comprehensibility; 

feasibility and execution of the assignments; 

time spent on the assignments, 

and the direct and indirect influences of the hosting general practitioner (GP) and 

the practical medical coaching group.

RESULTS 

과제를 수행하는 것은 인지된 교육성에 별 영향이 없었다. 자신을 입양한(hosting) GP로부터 코칭을 받는 것은 feasibility를 통하여 과제의 수행에 영향을 주었다. GP에 의한 코칭과 Practical medical coaching group언 인지된 교육성에 별로 영향이 없었다.

Performing the assignments had little effect on perceived instructiveness. Coaching by the hosting GP influenced the execution of assignments mainly by its effect on feasibility. Coaching by the GP and in the practical medical coaching groups barely affected perceived instructiveness.

DISCUSSION AND CONCLUSION 

이 모델은 MAP이 학습에 어떠한 기여를 하는가에 대한 insight를 준다. practical medical coaching group에게 MAP에 우선순위에 대해서 충분히 강조가 되지 않은 점, 그리고 GP에게 적절한 지침을 주지 않은 점 등으로 인해서 효과가 좀 떨어졌을 수 있다. 환자와 관련된 과제를 좀 더 섬세하게 계획할 필요가 있으며, 단순한 임상 경험을 더 높은 수준의 교육적 경험으로 향상시키기 위해서는 과제에 대한 성찰과정과 절차에 대한 피드백이 필요하다.

The model gives insight into the contribution of aspects of the Adoption Programme to student learning. The results are probably negatively influenced by the insufficient priority given to the Adoption Programme in the practical medical coaching groups and by inadequate instruction given to the GPs for the purposes of their coaching role. More careful planning of patient-related assignments is recommended. Reflection on assignments and feedback on procedures are needed to lift practical experience onto a higher educational level.

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INTRODUCTION

전통적으로 학부 의학교육은 이론 중심의 실습 전 과정에 이어서 임상실습이 이어지곤 했다. 임상실습, 예를 들어 환자 대면 시기가 더 빨라진다면 지식과 술기를 더 빨리 적용해볼 수 있을 것이다. 이러한 학생의 환자접촉은 의사들이 감독할 수 있으며, 의사들이 학생과 토론할 수도 있다.

Traditionally, undergraduate medical education consists of a preclinical, theory-oriented phase, followed by clinical clerkships. If clinical experience, such as patient contact, is programmed earlier in the curriculum, students will be able to apply their knowledge and skills in real practice at an earlier stage. Medical practitioners could supervise these contacts and discuss them with the students.

이런 것들이 1990년대에 MAP가 도입된 주요 이유였다.

These were the major reasons for educators at Maastricht University to set up a programme in which medical students were adopted by a general practitioner (GP).1 The Adoption Programme (AP) was initiated in 1990.

보통 GP는 1명의 학생을 받고, 학생은 과제를 받고, 수행하고 피드백을 받음. 학생은 총 60개 과제를 수행

Usually a GP’s practice receives 1 student at a time. The theme of the practice day is linked to the topics that are being addressed in the theoretical course at that moment and to the skills programme in the skills laboratory. Students are given specific assignments for each day of the programme, including observation of specific phenomena of the patient(s), taking the histories of patients with certain characteristics, visiting patients’ families and gathering relevant information.1–3 In all, students have to complete some 60 assignments.

이렇게 학생을 '입양'하는 GP는 적절한 환자를 arrange한다. 또한 프로그램의 배경정보와 지침이 담긴 프로그램북을 받게 되고, 모든 GP는 2시간의 코칭방법 교육을 받는다. 학생은 과제와 자신의 경험을 GP, Practical medical coaching group과 함께 토론한다.

The adopting GPs are expected to invite suitable patients or arrange a visit to a family for each day a student visits their practice. Participating GPs receive a programme book containing background information on the programme and instructions for each practice day. All GPs are prepared for coaching students by a 2-hour introductory programme given by staff at the Department of General Practice. The assignments and students’ experiences are discussed with the GP whose practice was visited and also in a subsequent session of the practical medical coaching group.

정기적 프로그램 평가로부터 학생들이 MAP를 좋게 생각한다는 것이 드러났고, 1996년 모든 학생들에게 의무사항이 되었다. 그 전 시기까지는 elective였다. 의무과정이 된 이후로 다시 평가를 하였고 학생과 GP모두 MAP가 좋은 학습경험이며, 잘 구성되어있다고 생각하는 것으로 드러났다. 그러나 학생들은 practical medical coaching group에서 받은 코칭에 대해서 비판적이었고, 자신들의 발전에 대해 논의하는 GP가 그다지 관심을 주지 않는다고(attention paid) 비판했다.

The regular programme evaluations showed that students appreciated the AP. As a result of this, in 1996, the AP became obligatory for all students; until that time it had been an elective.1–3 When the obligatory AP, in which an entire class participated, was evaluated, it appeared that both students and GPs considered the AP a valuable learning experience and thought that it was well organised.5 However, students were critical of the coaching they received in the practical medical coaching groups and the attention paid by GPs to discussing their progress

MAP에는 두 개의 주요한 learning process가 작동한다. action과 reflection on action이다. Action에는 세 개의 요소가 있다.

Two primary learning processes can be distinguished in the AP: action (carrying out the assignments) and reflection on action (discussion and feedback). Action consists of 3 essential aspects. 

First of all, the assignments must be comprehensible. That means that it must be clear to students what the requirements are and when they have to meet them. 

Secondly, it must be feasible for students to meet the requirements in the allotted time. These 2 aspects - comprehensibility and feasibility - determine how an assignment is executed. The amount of time needed to execute an assignment may differ between students. For instance, some students may examine a patient much more thoroughly than do others. Students who spend more time on assignments may learn more from them and hence value the AP more highly as a learning experience.
Furthermore, explanation of the assignments in the practical medical coaching groups contributes to the comprehensibility of the assignment, whereas the GP should provide the necessary conditions to ensure feasibility (e.g. execution in the available time). These actions are referred to by Kilminster and Jolly as the normative aspects of supervision.6

Reflection on action과 피드백은 AP 학습의 두 번째 측면이다. 이 시기에 학생들의 실제 경험들이 학습경험으로 전환되고, 이 시기에 supervisor가 중요하다.

Reflection on action and feedback constitute the second part of learning in the AP. In this phase students’ practical medical experiences are turned into real learning experiences, with supervisors playing an important role.6–9

GP와 Practical medical coaching group의 social scientist들은 학생들이 지식,기술,태도를 활발히 통합하는데 기여할 수 있다. 

the GP and social scientist facilitating the practical medical coaching groups, can contribute to students’ active integration of the knowledge, skills and attitudes that are called upon in the AP. The direct influence supervisors exercise upon students’ learning processes by discussing relevant experiences with the students have been described by Kilminster and Jolly as the formative aspect of supervision.

METHOD

Instruments

Out of the 33 items, 26 were used for the present study. Based on the content of these 26 items, 7 factors were derived. Table 1 shows the factors together with an example of an item. 

Five factors relate to the goals of the AP and the practice day, 

1 factor relates to the practical medical coaching groups and 

1 factor relates to the supervision by GPs. 

The questionnaire contained 1 item asking students to estimate the mean time they spent on the AP during 1 practice day. 

Several studies11,12 have shown that this method provides a reasonably valid indicator of the actual time spent. Comparisons of time estimates in retrospective reports and diaries have revealed that respondents generally overestimate the time spent in retrospective reports such as questionnaires. For the present study this means that the actual time spent by students was probably less than they reported.

Analysis

The factors comprehensibility, feasibility and execution were aggregated at student level by computing mean average scores across items for each student and for each factor. To test the reliability of each factor, Cronbach’s a was calculated. Correlations between the factors were calculated. Furthermore, data were analysed using a structural modelling approach. Structural equations modelling is concerned with testing theoretical models for the structure of functional relationships among multivariate data. Several statistics indicate whether the empirical data sufficiently fit the theoretical model: A chi-squared value divided by the degrees of freedom should be < 3; a P-value should be >0.00, and an adjusted goodness of fit index (AGFI) should be >0.80. Furthermore, the root mean square error should be < 0.70.13 The computer program AMOS Version 3.6 was used to test the hypothetical interrelationships between the factors in the model.14

DISCUSSION AND CONCLUSION

In order to stimulate the integration of knowledge, skills and attitudes of medical students in the preclinical medical curriculum, students at Maastricht University attend a GP’s practice on 8 days spread over 18 months. On these practice days students carry out assignments which have been introduced beforehand in practical medical coaching groups. The assignments are supervised by the adopting GP and discussed afterwards by the GP and in the group sessions.

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Med Educ. 2004 Dec;38(12):1236-43.

Learning in a clinical education programme in primary care: the Maastricht Adoption Programme.

Mainhard MT1, van den Hurk MM, van de Wiel MW, Crebolder HF, Scherpbier AJ.

Author information

Abstract

INTRODUCTION:

At Maastricht University, the integration of knowledge, skills and attitudes in preclinical medical education is promoted by an 'Adoption Programme', where students carry out assignments in a general practice setting. The assignments are explained and discussed in practical medical coaching groups. The aim of this study was to examine the relationships between the elements that affect learning in the programme.

METHOD:

Data from the evaluation questionnaires of 188 medical students were used to test a causal model of learning in the programme. A distinction was made between 'action' and 'reflection on action'. We examined the relationships between perceived instructiveness (the programme's value as a learning experience) and the following variables: comprehensibility; feasibility and execution of the assignments; time spent on the assignments, and the direct and indirect influences of the hosting general practitioner (GP) and the practical medical coaching group.

RESULTS:

Performing the assignments had little effect on perceived instructiveness. Coaching by the hosting GP influenced the execution of assignments mainly by its effect on feasibility. Coaching by the GP and in the practical medical coaching groups barely affected perceived instructiveness.

DISCUSSION AND CONCLUSION:

The model gives insight into the contribution of aspects of the Adoption Programme to student learning. The results are probably negatively influenced by the insufficient priority given to the Adoption Programme in the practical medical coaching groups and by inadequate instruction given to the GPs for the purposes of their coaching role. More careful planning of patient-related assignments is recommended. Reflection on assignments and feedback on procedures are needed to lift practical experience onto a higher educational level.