완전학습: 의학교육이 21세기에 합류할 시대(Acad Med, 2015)

완전학습: 의학교육이 21세기에 합류할 시대(Acad Med, 2015)

Mastery Learning: It Is Time for Medical Education to Join the 21st Century

William C. McGaghie, PhD

전통적인 임상의학교육은 Sir William Osler 가 New York Academy of Medicine 에서 1903년 발표한 19세기적 '임상역량의 습득'에 대한 생각에 기반을 두고 있다. 이 발표의 제목은 “The hospital as a college,” 로서 이후 'Aequanimitas'라는 제목으로 발표되었다. 1903년의 강연은 오슬러의 유럽의학교육에 대한 이전 경험을 반영하고 있으며, 오슬러는 유럽의학교육이 미국의 모델보다 우월하다고 판단했다. 오슬러는 이렇게 말했다.

Traditional clinical medical education is grounded in 19th-century thinking about the acquisition of clinical competence expressed by Sir William Osler in an address to the New York Academy of Medicine in 1903. The address, titled “The hospital as a college,” was published later in a collection of Osler’s essays titled Aequanimitas.2 The 1903 lecture reflects Osler’s earlier experience with European medical education which he judged superior to the extant American model. Osler states,

 

 

이 나라의 clinical clerk 시스템에는 급진적 개혁이 필요하다. 학생을 가르치는 자연적 방법natural method은 환자로부터 시작하고, 환자와 더불어 이어지고, 환자에 대한 의사의 연구로서 종결된다. 학생에게 어떻게 관찰할 것인가만 가르치면, 팩트로부터 교훈이 저절로 나올 것이다.

“The radical reform needed is in the introduction into this country of the system of clinical clerks.…” Osler continues: “In what may be called the natural method of teaching the student begins with the patient, continues with the patient, and ends his studies with the patient [emphasis added]. Teach him how to observe, and the lessons will come out of the facts themselves.”

'natural method of teaching'에 대한 오슬러의 생각은 존스홉킨스의 외과의사 동료인 William Halsted 역시 지지하게 되는데, 그는 1904년 “the training of the surgeon” 를 기술한 바 있다. 오슬러와 할스테드는 임상의학교육이 환자에 내제embodied 되어 있다고 보았다. 즉, 학생이 환자에 노출되어 오랜 시간 함께하게 되면, 이것으로 역량있는 의사가 되기에 충분한 훈련을 받은 것이다. 이는 수동적인 임상교육과정모델이며, 온전히 지속적 환자 경험에만 의존하고 있는 것이다. 오슬러와 할스테드는 구조화된, 단계화된 교육과정을 언급한 바가 없다. 피드백을 동반한 객관적 평가, 초심자 의사가 마스터가 되기 위한 guided reflection 등도 없다.

Osler’s idea about the natural method of teaching was endorsed by his Johns Hopkins surgeon colleague William Halsted,3 who described “the training of the surgeon” in 1904. Osler and Halsted argued that the clinical medical curriculum is embodied in patients—that is, student exposure to patients and experience over time is sufficient to ensure that physicians in training will become competent doctors. This is a passive clinical medical curriculum model based solely on longitudinal patient experience. Osler and Halsted made no place for structured, graded educational requirements; skills practice; objective evaluation with feedback; accountability; and guided reflection for novice physicians to master their craft.

오슬러의 natural method of teaching 에 대한 구조와 조작적 표현은 오늘날 의과대학/레지던트/펠로우/CME에서도 흔하게 볼 수 있는 것이며, "시간이 중요한time honored" 방식이 여전히 보존되고 지속되고 있다.

Structural and operational expressions of Osler’s natural method of teaching are seen every day at medical schools, residencies, fellowship programs, and continuing education where “time honored” practices (e.g., morning report, professor and grand rounds) are preserved and sustained.

완전학습 프로그램에 대한 메타분석 결과는 no intervention과 비교했을 때, 스킬 영역에 효과가 크고, 환자outcome에 대해서 중등도의 효과가 있다.

The meta-analytic results show that mastery learning programs are associated with large effects on skills and moderate effects on patient outcomes compared with no intervention.

저자들은 "완전학습 모델이 역량중심교육에 특히 관계가 깊으며, 이는 규정된 학습시간이 아니라 규정된 목표를 공동으로 강조shared emphasis하기 때문이다"라고 결론지었다.

The authors conclude, “The mastery model may be particularly relevant to competency-based education, given the shared emphasis on defined objectives rather than defined learning time.”6

Clinical experience alone is insufficient to guarantee the acquisition and maintenance of clinical competence. Osler’s natural method of teaching based solely on longitudinal clinical experience without curriculum objectives and measurement, performance expectations, learner practice with supervision, rigorous assessment with feedback, high achievement standards, and clear educational milestones is obsolete and simply does not work.

완전학습

Mastery Learning

완전학습은 여러 교육과학자들, 그리고 John Carroll이 1963년 연구하고 저술한 교육적 접근법으로부터 유래한다. 완전학습의 중심 교리는 다음과 같다.

Mastery learning is an educational approach that originates from research and writing beginning with John Carroll7 in 1963 and other early educational scientists including Fred Keller,8 James Block,9,10 and Benjamin Bloom.11 The central tenets of mastery learning are that

(1) 모든 학습자에게 교육 수월성을 기대하고 학습자는 이를 달성한다.

educational excellence is expected and can be achieved by all learners, and

(2) 완전학습에 있어서 학습자간 성과의 차이는 거의 없다.

little or no variation in measured outcomes will be seen among learners in a mastery environment.

완전학습은 K.A. Ericsson이 언급한 교육공학(educational engineering)의 문제로서 시작되었다. 핵심 질문은, '높은 교육적 태도와 강력한 성취동기를 가진 유망한 학습자들이 있을 때(의과대학생과 레지던트 등), 어떻게 교육환경을 설계해야 최대한의 학습성과를 얻을 수 있을까?' 였고, 이에 대한 대답은 모든 학습자가 완전(수준)성취를 이루게끔 촉진하는 교육조건을 만들고 관리하는 것이었다.

Mastery learning starts as an educational engineering problem, as articulated by K.A. Ericsson12 in his contribution to this thematic cluster. The key question is, given prospective learners with high educational aptitude and strong achievement motivation (e.g., medical students and residents), how shall we design an educational environment that produces maximum learning outcomes among all trainees? The answer is to create and manage a set of educational conditions—a curriculum and assessment plan—that promotes mastery level achievement among all learners.

완전학습에서는 학습자간 variation이 거의 존재하지 않으며, 반대로 학습시간은 학습자간 크게 다를 수 있다.

Mastery learning results are uniform with little or no variation among learners. By contrast, educational time can vary among learners.

 

다른 곳에서 기술된 바와 같이,

As stated elsewhere,14 

완전학습은 최소 아래의 일곱 개의 complementary feature를 가지고 있다.

mastery learning has [at least] the following seven complementary features: 

1. 베이스라인 평가 Baseline, or diagnostic testing; 

2. 점차 난이도가 증가하는 순서로 배치된 명확한 학습성과, Clear learning objectives, sequenced as units usually in increasing difficulty; 

3. 목표 달성을 위한 학습활동에 참여 Engagement in educational activities (e.g., deliberate skills practice, calculations, data interpretation, reading) focused on reaching the objectives; 

4. 각 학습유닛에 대한 최소 합격선 설정 A set minimum passing standard (e.g., test score) for each educational unit; 

5. 완전mastery 수준을 위한 단위 성취unit completion을 측정하기 위해 미리 설정된 최소 통과기준에 대한 형성평가
Formative testing to gauge unit completion at a preset minimum passing standard for mastery; 

6. 완전 기준을 달성하거나 넘어서면 다음 교육단계로 넘어가기
Advancement to the next educational unit given measured achievement at or above the mastery standard; and 

7. 완전 기준을 달성할 때까지 해당 유닛을 지속적으로 연습(학습)

Continued practice or study on an educational unit until the mastery standard is reached.

Mastery Learning Cluster

Future Directions

완전학습 교육과정의 도입되면서 점차 더 많은 의학교육프로그램들이  Berwick의 'categories of innovator'에서 '초기 도입자' 수준에 이르렀다.

A growing number of medical education programs now qualify for Berwick’s categories of innovator or early adopter25 as a result of implementing mastery learning curricula.

Conclusion

Thomas Kuhn은 정상과학을 다음과 같이 정의했다.

Writing in The Structure of Scientific Revolutions, Thomas Kuhn27 defined normal science as

the activity in which most scientists inevitably spend almost all of their time, [which] is predicated on the assumption that the scientific community knows what the world is like. Much of the success of the enterprise derives from the community’s willingness to defend that assumption, if necessary at considerable cost.

 

12 Ericsson KA. Acquisition and maintenance of medical expertise: A perspective from the expert performance approach and deliberate

17 Inui TS. The charismatic journey of mastery learning. Acad Med. 2015;90:1442–1444.

18 Lineberry M, Park YS, Cook DA, Yudkowsky R. Making the case for mastery learning assessments: Key issues in validation and justification. Acad Med. 2015;90:1445–1450.

20 McGaghie WC, Barsuk JH, Cohen ER, Kristopaitis T, Wayne DB. Dissemination of an innovative mastery learning curriculum grounded in implementation science principles: A case study. Acad Med. 2015;90:1487–1494.

21 Yudkowsky R, Park YS, Lineberry M, Knox A, Ritter EM. Setting mastery learning standards. Acad Med. 2015;90:1495–1500.

22 Eppich WJ, Hunt EA, Duval-Arnould JM, Siddal VJ, Cheng A. Structuring feedback and debriefing to achieve mastery learning goals. Acad Med. 2015;90:1501–1508.

23 Cohen ER, McGaghie WC, Wayne DB, Lineberry M, Yudkowsky R, Barsuk JH. Recommendations for reporting mastery education research in medicine (ReMERM). Acad Med. 2015;90:1509–1514.

24 Griswold-Theodorson S, Ponnuru S, Dong C, Szyld D, Reed T, McGaghie WC. Beyond the simulation laboratory: A realist synthesis of clinical outcomes of simulation based mastery learning. Acad Med. 2015;90:1553–1560.

25 Berwick DM. Disseminating innovations in health care. JAMA. 2003;289:1969–1975.

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Acad Med. 2015 Nov;90(11):1438-41. doi: 10.1097/ACM.0000000000000911.

Mastery learning: it is time for medical education to join the 21st century.

McGaghie WC1.

Author information

• 1W.C. McGaghie is professor of medical education, Northwestern University Feinberg School of Medicine, Chicago, Illinois.

Abstract

Clinical medical education in the 21st century is grounded in a 19th-century model that relies on longitudinal exposure to patients as the curriculum focus. The assumption is that medical students and postgraduate residents will learn from experience, that vicarious or direct involvement in patient care is the best teacher. The weight of evidence shows, however, that results from such traditional clinical education are uneven at best. Educational inertia endorsed until recently by medical school accreditation policies has maintained the clinical medical education status quo for decades.Masterylearning is a new paradigm for medical education. Basic principles of mastery learning are that educational excellence is expected and can be achieved by all learners and that little or no variation in measured outcomes will result. This Commentary describes the origins of mastery learningand presents its essential features. The Commentary then introduces the eight reports that comprise the mastery learning cluster for this issue of Academic Medicine. The reports are intended to help medical educators recognize advantages of the mastery model and begin to implementmastery learning at their own institutions. The Commentary concludes with brief statements about future directions for mastery learning program development and research in medical education.

PMID:

 

26375269

 

[PubMed - indexed for MEDLINE]