기초의학자 없는 기초의학교육 통합? - 교육과정 개혁에서 개별 교수의 중요성 재고 (Academic Medicine, 2015)

기초의학자 없는 기초의학교육 통합? - 교육과정 개혁에서 개별 교수의 중요성 재고

Integrating Basic Science Without Integrating Basic Scientists: Reconsidering the Place of Individual Teachers in Curriculum Reform

Robin Hopkins, PhD, Daniel Pratt, PhD, Judith L. Bowen, MD, and Glenn Regehr, PhD

기초의학과 임상의학 통합에 대한 요구는 의학교육에서 교육과정 변화에 대한 논의에서 매번 등장하는 주제이다. 그러나 그 역사를 살펴보면 '통합'이라는 주제가 반복적으로 등장하지만, 의미있는 변화를 가져온 적은 거의 없다. 이러한 "차이 없는 변화"를 반복하지 않기 위해서 의학교육계는 효과적인 통합 없이 매번 비슷한 문제만 제기되는 현실을 극복하기 위해서 의학교육개혁에 대한 지금까지의 주된 접근법을 다시 살펴볼 필요가 있다. '통합'을 도입하는 다양한 관점을 제공하기 위하여 저자들은 복잡하고 진화하는 환경에서 일어나는 전환으로서의 교육의 변화를 살펴보았다. 

The call for integration of the basic and clinical sciences plays prominently in recent conversations about curricular change in medical education; however, history shows that, like other concepts related to curricular reform, integration has been continually revisited, leading to incremental change but no meaningful transformation. To redress this cycle of "change without difference," the medical education community must reexamine the approach that dominates medical education reform efforts and explore alternative perspectives that may help to resolve the cyclical "problem" of recommending but not effecting integration. To provide a different perspective on implementing integration, the authors of this Perspective look to the domain of educational change as an approach to examining the transitions that occur within complex and evolving environments. 

여기에 대해 다룬 문헌들을 살펴보면 변화에는 다양한 수준이 관여되어 있으며, 시스템적 구조의 문제 뿐만 아니라 그 변화의 한가운데에 있는 개개인에 초점을 맞춰야 함을 강조한다. 교육과정 통합을 이루는데 어려움을 겪는 한 가지 주된 이유는 변화를 위한 노력이 주로 '교육과정 구조'에 초점을 맞추고 있어서, 각 레벨에서 필요한 것이 무엇인지, 개개인에게 필요한 것이 무엇인지는 소홀히한다는 점이다. 개별 교육자들, 특히 기초의학자들에게 대한 적절한 관심을 통해 의학교육계는 통합교육이 이들에게 어떠한 영향을 줄 것이며, 그들이 가르치는 영역에 어떠한 영향을 미칠 것인지 알아볼 필요가 있다.

This area of literature both acknowledges the multiple levels involved in change and emphasizes the need not only to address systemic structure but also to prioritize individuals during times of transition. The struggle to implement curricular integration in medical education may stem from the fact that reform efforts appear to focus largely on transformation at the level of curricular structure as opposed to considering what learning needs to occur at each level of change and highlighting the individual as the educational change literature suggests. To bring appropriate attention to the place of individual educators, especially basic scientists, the medical education community should explore how the mandate to integrate clinically relevant material may impact these faculty and the teaching of their domains.

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• The predominant curricular model of the past 100 years has been one in which students spend 2 years in the university setting learning the medical, or “basic” sciences, and then 2 years in teaching hospitals learning at the bedside of patients.

• 현 교육의 문제 however, many contemporary medical educators now perceive this separation of theoretical and practical knowledge as problematic because they believe that, firstly, this separation weakens the transfer of knowledge to the practical context, and secondly, that students are often unmotivated to learn large amounts of detailed information that seems disconnected from the practical setting.2–7

• 왜 계속 반복되기만 하는 것일까? To move toward actually implementing curricular integration, therefore, a relevant question to ask is, Why does this perpetual discussion of the same theme continue with little substantial change in the training of physicians?

• Integration: Then and (Still) Now
• The field of medical education has been working toward curricular integration for over 60 years. 
• Case Western Reserve University School of Medicine is recognized as implementing the first integrated curriculum in the early 1950s, as lectures began to incorporate clinical examples or include presentations from visiting physicians.13 
• Later, McMaster University moved toward integration with the introduction of problem-based learning in 1969. One of the expressed objectives of this innovative curriculum was to integrate the basic and clinical sciences in the context of clinical problems.14 
• Similarly, in the early 1990s, the University of Calgary Faculty of Medicine introduced a curriculum through which relevant basic and clinical science material were to be learned in the context of “clinical presentations”—that is, the different ways patients present to physicians, such as with a headache, abdominal pain, or fever.13 Thus, in the context of different schools and in the form of different curricular structures, integration was a recurrent theme of reform throughout the second half of the 20th century.15 
• Yet, today, curricular integration is not fully actualized and continues to appear as a central recommendation in reports for curricular reform. 
• The Future of Medical Education in Canada: A Collective Vision (the FMEC report) acknowledges the integration and timing of the basic and clinical sciences as one of the priority areas to be addressed in the training of physicians in Canada.16,17 Specifically, the report recommends that “both human and biological sciences must be learned in relevant and immediate clinical contexts throughout the MD education experience”16(p20) and that the basic and clinical sciences “must be increasingly integrated so that students think about clinical applications as they learn basic sciences and about scientific principles as they learn clinical skills.”16(p20) 
• Similarly, Educating Physicians: A Call for Reform of Medical School and Residency recommends integration of formal knowledge and clinical experience.8 A commission on medical education sponsored by the Robert Wood Johnson Foundation recommends that “medical schools should ensure that the sciences of medical practice be integrated throughout the entire course of study.”18(p413) Other experts in the field of medical education, including a former editor of this journal, have echoed this recommendation.19

• 지금껏 매번 똑같아 왔다. After reviewing major reports of reform throughout the past century, Christakis21(p706) came to a similar conclusion, writing, “Typically these reports identify strikingly similar problems with medical education, claim that previous reports have gone relatively unheeded, argue that reform is essential and urgent, and prescribe corrections that are also strikingly similar.”

• The literature does acknowledge that modifications and adjustments have been occurring constantly in medical education to keep training current with the advancements of medical science and technology, but describes these changes as being superficial, leaving the basic and clinical sciences still largely segregated.20,22–24 The consensus appears to be that although changes have occurred, they remain at the level of curricular tinkering25 rather than producing fundamental change.

• 어떤 질문을 해야 하는가? She states that “we can be assured that we don’t need to keep asking, ‘what should we do?’ but rather ‘how can we get there?’”26(pS32) We would suggest, however, that to answer the question of how to get there, medical educators must first ask why change has been so hard.

• Commonly referred to as the “paradox of change without difference,”30 this phenomenon, describing the minimal impact of educational reform efforts, largely echoes the recurrence of the same recommendations that plague medical education.

• 교사가 중요하다. Fullan notes that “a teacher cannot sustain change if he or she is working in a negative school culture; similarly, a school can initiate and implement successful change, but cannot sustain it if it is operating in a less than helpful district; a district cannot keep going if it works in a state that is not helping to sustain reform.”31(p18)

• Woodbury32 found substantial evidence that the thinking and practice of individual teachers centrally impacts educational change. Researchers in educational change largely agree that any attempt to significantly change curricula must start with teachers33 and continue to hold them at the center.34

• By contrast, the literature regarding the implementation of integration in medical education tends to focus on the level of curricular structure.

• 기초의학자들의 목소리는 들리지 않는다. Amidst the overlying conversation regarding various integrated structures, the voices of individual educators— particularly those of basic scientists— appear to be lost.

• 그런데 그 와중에서도 이들의 반대가 심하다는 종종 등장한다. Despite the seemingly muted voice of basic scientists in the literature, one challenge of implementing curricular integration often mentioned is resistance from these faculty. In general, basic scientists are reported as having a negative attitude toward change. Different schools’ accounts of implementing integration highlight the unwillingness of basic science faculty to adapt to a new curriculum.2,11,36 Some report that basic scientists perceive integration to be unidirectional40 and that they are uncomfortable trying to put their teaching into clinical contexts because of their lack of clinical knowledge.6 When forced to integrate, basic science departments are noted as displaying “anxiety, antipathy, lack of cooperation, and general mistrust.”41(p15)

• 교사가 중요하다(2) As summarized by Fullan,31 “educational change depends on what teachers do and think—it’s as simple and complex as that.”

• 해야 할 연구들 To this end, as Fullan31 suggests, medical educators might conduct research on better understanding the experiences of basic scientists who are at different points along the process of reform. 
• What is the experience like for those who have undergone, are undergoing, or anticipate such a change? 
• How do they understand the teaching of basic science within this new mandate of “clinical relevance”? 
• What learning must occur in order for them to get there? 
• What do they feel they have to give up in this process? 
• Do they perceive any benefits, and if so, what are they?

• 개혁의 과제는 늘 비슷하고, Current reforms in medical education reiterate many of the same challenges the field has been voicing for over half a century:
• 그 해결방법도 새롭지 않다. The current approach to addressing these concerns is also nothing new;

• The educational change literature speaks to the importance of attending to the multiple levels of change, but in particular to the individual teachers who will be the ones actually implementing the change. Given the complexity and collaborative nature of educational reform, we suggest delving beneath the models of curricular structure that dominate current conversations, and developing an understanding of what those curricular changes mean to those who are asked to live them and carry them out. Focusing not only on what we are integrating but also on who we are integrating may be the key to moving beyond change without difference, and enacting change that is both successful and meaningful.

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Acad Med. 2015 Feb;90(2):149-53. doi: 10.1097/ACM.0000000000000437.

Integrating basic science without integrating basic scientists: reconsidering the place of individual teachers in curriculum reform.

Hopkins R1, Pratt D, Bowen JL, Regehr G.

Author information

Abstract

The call for integration of the basic and clinical sciences plays prominently in recent conversations about curricular change in medical education; however, history shows that, like other concepts related to curricular reform, integration has been continually revisited, leading to incremental change but no meaningful transformation. To redress this cycle of "change without difference," the medical education community must reexamine the approach that dominates medical education reform efforts and explore alternative perspectives that may help to resolve the cyclical "problem" of recommending but not effecting integration. To provide a different perspective on implementing integration, the authors of this Perspective look to the domain of educational change as an approach to examining the transitions that occur within complex and evolving environments. This area of literature both acknowledges the multiple levels involved in change and emphasizes the need not only to address systemic structure but also to prioritize individuals during times of transition. The struggle to implement curricular integration in medical education may stem from the fact that reform efforts appear to focus largely on transformation at the level of curricular structure as opposed to considering what learning needs to occur at each level of change and highlighting the individual as the educational change literature suggests. To bring appropriate attention to the place of individual educators, especially basic scientists, the medical education community should explore how the mandate to integrate clinically relevant material may impact these faculty and the teaching of their domains.

PMID:

 

25140528

 

[PubMed - in process]