영국의 네 개 신생 의과대학들의 의학교육에 대한 새로운 접근법

New perspectives—approaches to medical education at four new UK medical schools

Amanda Howe, Peter Campion, Judy Searle, Helen Smith

영국 의과대학 학생 수가 증가하면서, 네 개의 의과대학이 신설되었다. 저자들은 이들 학교가 의학교육에 대한 접근방식이 어떤 면에서 공통적인가를 보고자 했다.

With the expansion in UK medical student numbers, four new medical schools have been established. The authors, all senior faculty members at these new schools at the time of writing, discuss how much the schools have in common in their approaches to medical education

---

더 많은 의사 양성을 위해서 영국정부는 1998년과 2005년 사이에 의과대학학생 수를 57%늘렸다 (3749명에서 5892명). 이를 위해서 기존 학교들의 정원이 늘어나기도 했고, 이학대학 졸업자들을 대상으로 한 더 짧은 의과대학 프로그램을 만들기도 했고, 동일한 프로그램을 다른 학교에 '쌍둥이'프로그램으로 마들기도 했고, 네 개의 새 의과대학을 만들기도 했다. 이 중 네 개의 새로운 의과대학이 어떤 면에서 공통적인 vision을 가지고 있는지 그 rationale을 보고자 한다.

To create more UK doctors, the government has funded an increase in medical student numbers of 57% (from 3749 to 5894)1 between 1998 and 2005. This has been done by increasing student places at existing medical schools; creating shortened programmes open to science graduates; “twinning” arrangements, which host an existing curriculum at a new site; and four entirely new schools (table 1). Through reflection on our experiences and the literature evidence, we examine to what extent these new schools have a common vision and approach to undergraduate medical education, and we discuss the rationale for and likely outcomes of these new ventures.

핵심 요소

Key perspectives

한 의과대학이 가진 이념은 교육과정에서 잘 드러난다. 영국의 의과대학에 대한 인증/등록 기관인 GMC는 지난 십년간 의학교육의 혁신을 요구해왔고, 다음의 것들을 요구했다.

A key aspect of a medical school’s ideology is its approach to the curriculum. The UK accrediting and registering body for medicine, the General Medical Council, has for the past decade called for reforms in medical education2 and recommended courses that

integrate teaching of basic sciences (anatomy, biochemistry) with clinical and social sciences, 

make use of community as well as hospital healthcare settings, 

increase overall patient contact, and 

provide greater student choice. 

이에 맞춰서 새로운 교육과정은 다음의 특징을 가진다.

New courses are likely to...

encourage learning methods that directly link new knowledge to patient care,3 

modernise approaches to basic science (in particular anatomy4), 

increase emphasis on appropriate consultation skills5 and attitudinal learning, 6 and 

promote a more humane and supportive learning environment.7

또한 이들 학교는 학생 선발과 평가에도 혁신적인 접근법을 도입할 기회가 있었다.

New schools also have the opportunity to take innovative approaches to selecting candidates for medical education and to the assessments that underpin the direction of student learning. How do the four new medical schools deal with these issues?

학생 선발과 입학정책

Student selection and admissions policies

새로운 의과대학은 "접근성의 확대" 논쟁에 영향을 받았고, 학업성적보다 우선하여 필요한 것이 무엇인지를 재고려하여 나이나 사회인구적 특성에 무관하게 좋은 학생들을 모집하였다.흥미롭게도 첫 입학생 중 고등학교를 졸업하고 바로 입학하지 않은 비율이 20%~60%에 달했다.

The new medical schools are funded for UK and European Union applicants, and their approaches have been influenced by the “widening access” debate.8 9 They have reconsidered what constitutes necessary prior academic attainment, and they attempt to attract good candidates regardless of age and sociodemographic and school background. Interestingly, although all the new schools offer a full five year undergraduate entry course with no reduction for those who already hold a first degree, between 20% and 60% of their first cohorts have not come directly from secondary school.

네 학교 모두 선발과정에서 학업적 기준은 그저 한 단계일 뿐이며, 표준화된 면접이 기준(norm)이고, 선발의 일부는 비학업적 준거에 따라서 이루어진다. 또한 기존의 선발과는 다른 배경을 가진 지원자를 장려한다. 고등학교 졸업 직후에 지원하지 않은 지원자의 학업적 능력은 GAMSAT과 같은 screening tool처럼 다른 도구를 활용해서 판별한다.

All the schools claim to use selection procedures for applicants in which academic criteria are only one hurdle in the process, standardised interviews are the norm, and part of the selection rests on non-academic criteria. All have local access links and programmes to encourage applicants from non-traditional backgrounds (for example, 15% of the intake at the University of East Anglia are from access schemes whereby students from non-traditional backgrounds can do a foundation year of science preparation). The academic performance of applicants who are not coming directly from school is assessed in a variety of ways, with the Peninsula Medical School trialling the GAMSAT (graduate Australian medical schools admissions test)10 as a screening tool. Table 2 gives further details of the selection procedures.

교육과정 설계

Curriculum design

통합

Integration

네 개 학교는 모두 전 과정에 걸쳐서 '환자'에 초점을 둔다. 임상-비임상의 기존 구분을 두지 않고, 기초-임상의 구분도 두지 않는다. 교육과정 구조는 '달성해야 할 성과'를 중심으로 디자인되고, 체계적으로 임상과 각종 술기를 반복하여 익힌다. "내 옆에 붙어있어요" 식의 도제식 교육을 지양하여 학생의 학습경험의 편차가 커지는 것을 방지한다.

All the new schools integrate student learning by focusing on patients throughout the course. Their curriculums show no traditional divide between clinical and non-clinical phases, nor between basic and applied science. They structure learning around desired outcomes11 and systematically rehearse clinical and technical skills through simulated and supervised “near life” situations. They aim to reduce apprenticeship “tag along with me” learning, which risks wide variation in student opportunities.

선택 과정

Student selected modules

특정한 주제에 대해 더 익히거나 연구하고 싶은 학생을 위하여 네 개 학교 모두 GMC가 student selected module이라고 칭하는 과정을 도입했다. 이 과정은 전체의 30%정도를 차지하며, 법/보건경제 등의 전문분야 뿐만 아니라 사회과학과 인문학도 포함하고 있다. 이 과정에서 학생들은 졸업후교육에서 사용되는 학습법/평가법을 따르게 된다(peer presentation 등). 

For students to acquire critical appraisal and research skills, the four schools have adopted repeated use throughout the course of what the GMC called student selected modules. These occupy about 30% of course time and draw on the social sciences and humanities as well as professional fields such as law and health economics. In these modules, students encounter methods and assessment modalities similar to those used in postgraduate education—such as peer presentations. All courses include a summatively assessed research project for senior students.

합목적성

Fitness for purpose

유구한 역사에서 오는 제한이 없었기 때문에, 이들 학교는 새로 의사들을 교육하는 것에 있어서 '환자를 포함한 다학제간 팀으로서 일하는 것'이라는 것을 목적으로 삼을 수 있었다. 

Without historical constraints, the schools have designed their curriculums with the aim of creating junior doctors fit for the purpose of working as part of multidisciplinary teams that include the patients. 

Early patient contact, 

systematic consultation skills linked to clinical practice, and 

group learning settings are used to emphasise the responsibilities of the students towards others. 

학생이 발전하는 과정은 지적인 측면 뿐만 아니라 태도적인 측면도 평가하였고, 이것이 평가를 단순히 후향적 판단이 아니라 건설적으로 목적을 달성하게 하고, 학생의 약점을 조기에 발견하여 개입할 수 있게 하였다.

Student progress is assessed on attitudinal as well as intellectual progress, thus ensuring that fitness to practise is a formative curricular goal, rather than a retrospective judgment, and enabling early diagnosis and intervention in areas of weakness (see table 4).

학습법과 평가법

Learning methods and assessment

자연과학에 대한 새로운 접근법

New approaches to life sciences

기초 자연과학은 그 양과 접근법 모두에 있어서 근본적인 변화가 있었다. 해부와 실험실 실습이 "prosection"으로 바뀌었고, 정교한 모델과 컴퓨터 이미지를 활용하였다. 네 학교는 여기서 가장 서로 달랐는데, 해부학 교육에 있어서 각각의 철학을 반영하였다. 

The basic life sciences are radically altered both in amount and approach, with dissection and laboratory work being replaced in three of the four schools by prosection (pre-dissected material displayed for students to study, examine, and touch) and use of sophisticated models and computerised imaging. The schools are most diverse in this regard, expressing their individuality and preferred philosophies through such issues as anatomy teaching, with Peninsula Medical School not using cadavers at all whereas Brighton and Sussex Medical School includes dissection throughout the course.

더 나은 의사소통과 통합을 위한 정보기술의 활용

Information technology for better communication and integration

네 학교 모두 전자교육과정프로그램 (Blackboard 또는 Studentcentral이라고 불리는)을 사용하였다. 빠른 접근이 가능하고, 평가에 걸리는 시간이 짧고, 의사소통이 빨라지고, 모든 교사,평가자,학생이 어느 곳에서나 접근가능해졌다. 이것은 또한 자기주도적 학습, E-learning의 중추이기도 하다.

All four schools use electronic curriculum programmes (“Blackboard” or “studentcentral”) to underpin and coordinate their courses. These allow rapid access to information and quick turnaround of evaluation and messaging, and allow all tutors, assessors, and students at any site to look at the curricular context of their own particular contribution. These managed learning environments form a strong backbone to self directed and e-learning

임상 강조

Clinical emphasis

네 개 학교 모두 환자와의 조기 접촉을 도입하였다. 전체 시간은 다른 의과대학과 큰 차이가 없을지 몰라도 구조화 된 것이 달랐고, 그 기본 원칙은 전공과에 기초하는 것이 아니라, 환자의 관점에 기초하여 학습하는 것이다.

All the schools have adopted early contact with patients, supported by large numbers of clinical (NHS) staff as tutors in both campus based teaching and clinical placements. Although the overall time commitment to clinical placements is probably no greater than in other medical schools, they seem to be organised differently. The principle is to base learning on the patient perspective, rather than by specialty.

평가

Assessment

형성평가가 일반적으로 사용되며, 총괄평가는 '다음 단계로 넘어갈 수 있는가'를 보기 위한 목적으로 사용되는 정도이다. 

Under the close scrutiny of panels of visitors from the GMC’s Education Committee, each school has developed rigorous procedures to assess students’ knowledge, skills, attitudes, and fitness to practise. Formative assessment is generally used to enable students to appreciate their progress, while summative tests ensure that only those who are performing adequately can progress to the next stage of the course or to their preregistration year. Peninsula Medical School has adopted a progress test (run four times a year) for its major summative assessment of applied medical knowledge.14 

OSCE는 다음의 것을 평가하기 위하여 사용된다.

The objective structured clinical (and practical) examination (OSCE or OSCPE) is commonly used to assess...

clinical skills; 

projects and presentations are used to assess other academic ability; 

포트폴리오는 태도와 행동을 보여준다.

and portfolios of evidence from students and tutors reveal attitudes and behaviour. 

Peer and tutor feedback and reflection on experiential learning help students to compile a summatively assessed “portfolio report.” The time needed to perform and validate such detailed, multi-faceted assessments may prove challenging as student numbers increase over the first five years, and more so if further expansion occurs.

더 넓은 맥락에서..

The wider academic context

대부분의 대학에서 교육과 연구 사이에는 상당한 긴장감(tension)이 존재한다. 그리고 신생 학교도 예외는 아니다. 

There is considerable tension between teaching and research roles in most universities,15 and this is particularly acute for the new schools—where staff numbers are still building up, there are major educational and organisational challenges in setting up the new courses, and the research units have no institutional track record. 

Peninsula Medical School has developed research institutions rather than traditional clinical academic departments as the main “home” for its staff, sending a strong message about the value of education in a research-rich environment. 

Hull York Medical School is placing staff active in research in existing departments of the universities of Hull and York, so providing the infrastructure for research and critical mass for research groups. Time and the research assessment exercise, which compares research performance across UK universities, will tell how successful these arrangements are.

이들 신생 대학에 대해서는 연구가 충분히 되어 있지 않다. 여러 변화에 대한 근거가 아직 부족하다. 

The innovations in the new schools may themselves be under-researched.16 Evidence is lacking for many of the changes made: for example, the outcomes of new admissions policies cannot be evaluated until the changes have been made. No substantive funding has been offered for research into the comparative outcomes of the new courses across Britain as a whole. A longitudinal cohort study to compare outcomes would be of great value, and, given the taxpayers’ investment in the expansion of medical school places, this does not seem an unreasonable proposal. A comparative survey is currently in progress for the Department of Health, which includes representation from the new schools, and this may reveal further research needs.

결론

Conclusion

네 개의 대학을 간략히 보았고, "새로운 도화지"에 그리는 것인 만큼 핵심 영역의 접근법이 비슷한 것으로 보인다. 

The four new medical schools examined briefly here, though differing in detail, seem to be using similar approaches to key areas of medical education and have capitalised on the opportunity of development from a “clean slate.” 

They have used evidence and current policy to modernise the selection process, the curriculum, and learning activities in accordance with the expectations of the GMC and the public and the new opportunities provided by modern information technology. 

Emphasis is placed on changing the “culture” of medical learning—to one that has high academic as well as vocational expectations, where the role models experienced are spread across the whole of the NHS, and where students as learners and patients as teachers are accorded higher value than in the past.

아직 위험요인이 남아있는데, 최악의 경우는 기존과 다른 배경을 가진 학생들이 기존과 다른 교육과정을 만나서 대규모로 낙제하는 것이다. NHS가 medical training을 확장할 수 있는가도 관건이며, 높은 질의 교육개발을 위한 스텦이 충분한지도 관건이고, 연구와 교육 사이의 긴장 등도 있다. 그러나 이러한 시나리오로 나타날 가능성이 높다는 근거 또한 없다.

There are areas where one might predict problems. “Worst case” scenarios include a high dropout or failure rate among students from non-traditional backgrounds facing the uncertainties of unconventional curriculums; an inability of the NHS to deliver the expanded clinical placement capacity needed to underpin the expansion in medical training; inadequate academic staffing to ensure a high quality of educational development and delivery17; conflicting tensions between research and teaching in universities; and a failure to establish a credible research base. There is, however, no evidence to suggest that these scenarios are more likely to come to pass than the more positive ones envisaged in this article.

이 네 개 의과대학은 21세기 의학교육의 선구자가 될 것이다.

These four new medical schools aspire to be the pioneers of 21st century medical education, driven by the enthusiasm of local champions and the need to expand the national workforce. Their shared vision suggests a common set of educational principles, firmly grounded in best current practice but seeking to discover new routes to the goal of quality teaching and learning. The benefits should come to all—when we need the help of one of the next generation of doctors.

---

BMJ. 2004 Aug 7;329(7461):327-31.

New perspectives--approaches to medical education at four new UK medical schools.

Howe A1, Campion P, Searle J, Smith H.

Author information

Comment in

• Promises and delivery--a research imperative for new approaches to medical education. [BMJ. 2004]