● 교육자로서 의사의 전환적Transformative 전문성개발(Acad Med, 2003)

교육자로서 의사의 전환적Transformative 전문성개발(Acad Med, 2003)

Transformative Professional Development of Physicians as Educators: Assessment of a Model 

Elizabeth G. Armstrong, PhD, Jennifer Doyle, MA, and Nancy L. Bennett, PhD

의사-교육자에게 가해지는 동일한 압력이 그들의 미래동료가 가르침을 받고 훈련을 받는 방식의 변화에도 가해지고 있다. 그러나 너무 자주 추가적인 진료의 압박이 환자도 잘 돌보면서 가르치는 것도 잘 하는 것을 어렵게 만든다.

Those same forces challenge physi- cian–educators to change the way their future colleagues are taught and trained. Too often, however, the addi- tional clinical pressures on medical faculty make it difficult to teach effectively while caring for patients.

배경

BACKGROUND

거의 20년간 의학교육개혁은 미국의 의과대학 학장들, 의학교육자들, 정책개발자들에게 분명한 메시지를 주었다.  

For nearly two decades, medical edu- cation reform has been the clarion call of the United States’ medical school deans, medical educators, and policy- makers.1,2

• GPEP레포트 In 1984, the Association of American Medical Colleges’ Report of the Project Panel on the General Pro- fessional Education of the Physicians (GPEP Report) 3

• 메이시 재단 Five years later, the Josiah Macy Jr.Foundation convened a panel of med-ical educators to study clinical educa-tion, which also reported that reform must occur to reflect the change staking place in medical practice.4

• 1989년의 설문 A 1989 Robert Wood Johnson survey of1,369 U.S. medical school deans and faculty members found that a large majority (67%) of those educators saw a need for ‘‘fundamental changes’’ in medical students’ education.5 More recent reports have reaffirmed this need.

• Training Tomorrow's Doctor The Commonwealth Fund’s Task Force on Academic Health Cen-ters, in its April 2002 report, Training Tomorrow’s Doctors: The Medical Edu-cation Mission of Academic Health Centers 6

교육과정 개혁에 대한 요구에 대하여 HMS와 HGSE는 Macy 재단의 지원에 힘입어 1995년 의사-교육자를 위한 프로그램을 도입하였다. 

Responding to these calls for curric- ular reform, Harvard Medical School (HMS) and the Harvard Graduate School of Education, with funding from the Josiah Macy Jr. Foundation, in 1995 initiated the Program for Physi- cian Educators as an intensive pro- fessional development program for physicians and scientists actively en- gaged in educating future physicians.

전환학습Transformational learning 은 자기자신과 자신이 하는 일에 대한 새로운 관점을 개발하는 것, 그리고 그러한새로운 관점에 따라 행동하는 방식을 변화시키는 것으로 정의된다. 특히, 이 프로그램에서는 임상가와 과학자를 자기-성찰적 교육자로 변모시키는 것을 목적으로 하며, 이들은 cross-discipline, cross-school 커뮤니티를 이루게 될 것이고, 궁극적으로 자신이 소속된 기관은 물론 더 넓은 차원에서의 change agent가 될 것이다.

Transformational learning is defined as developing a new perspec- tive about one’s self and work, and changing one’s actions in light of that new perspective.7 Specifically, the pro- gram proposed to transform clinicians and scientists into self-reflective edu- cators who would form cross-discipline and cross-school communities of prac- tice, and would thus serve as change agents both at their home institutions and more globally.8

HMPPE는 이러한 전환학습을 촉진하는 요소를 기반으로 설계되었다. 특히, 이 프로그램에서는 2주간 고강도 immersion 경험을 하게 되며, 여기에 이어서 1주짜리 spring session이 진행된다. 프로그램의 목적은 "의사와 기초과학자를 교육자 professional development"하는 것이며, 4개의 상호관련된 주제로 구성된다.

The design of the Harvard Macy Program for Physician Educators was based on elements demonstrated to fos- ter such transformational learning.9–11 Specifically, the program was an in- tensive immersion experience in res- idence: a two-week winter session followed by a one-week spring session. The explicit goal of the program, ‘‘to enhance the professional development of physicians and basic scientists as educators,’’ was translated into four interwoven themes:

• learning and teach- ing,

• curriculum design,

• evaluation, and

• leadership.

 

이 프로그램에서 교육을 맡은 교수들은 "고난도, 고지원high-challenge, high-support" 환경을 제공한다. 첫 번째 iteration 후에, 참여자는 프로그램의 faculty로 돌아오게 되며, 이들이 프로그램 코호트 사이의 실천공동체 형성의 기반이 된다.

Harvard faculty members who teach in the program provide a ‘‘high-challenge, high-support’’ envi- ronment. Following the first iteration of the program, participants were invited to return as program faculty members, laying a foundation for building com- munities of practice across program cohorts.12

이 실험실laboratory에서 학습은 사회적 프로세스로 상정된다. 따라서 참여자와 교수자 모두 각 참여자의 성찰능력과 새로운 아이디어의 통합에 있어서 필수적인 존재이다. 교육 형식에는...

In this laboratory, learning is assumed to be a social process, so colleagues— both fellow participants and faculty members—are viewed as essential to each participant’s ability to reflect on and integrate new ideas. Formats in- clude

• interactive whole-group presen- tations and exercises,

• problem-based learning,

• observations,

• reflective use of journals, and

• discussion in large and small groups.

 

(상호)관찰과 공동의 경험에 대한 성찰을 바탕으로, 참여자들은 교수-학습에 대한 자신의 가정을 명시적으로 드러내고, 검증한다. 익숙한 것들을 낯설게 만든다. 이를 통해서, 개개인은 한 발 뒤로 물러나서 자신의 가정을 새로운 관점에서 보게 되고, 그것을 동료의 도움을 받아서 설명해보는 경험을 갖는다. 이러한 assumption을 활용하고, 자신의 내면틀internal scaffolding 또는 기존의 지식과 경험상의 조직organization에 반하여 assumption을 검증하는 과정에서 참여자들은 자신만의 교육에 대한 원칙을 정립하고, 그 원칙을 extrapolate하여 action step을 구성delineate하고 자신의 교육과 scholarship 향상을 이룬다. 이 모델에서 관찰observation은 학습에 대한 가정을 드러내는 수단이며, 참여자들로 하여금 (자신의) 교육원칙을 구성하게 하여, 이것이 자신의 사고와 교육을 지속적으로 guide하게 한다.

Using observation and reflection on shared experiences, par- ticipants make explicit, and test, their assumptions about the teaching/learn- ing transaction; the familiar is made unfamiliar. That is, individuals are asked to step back and look at an experience with new eyes to help them articulate their assumptions with the help of a group of colleagues. Using these as- sumptions, and testing them against each participant’s ‘‘internal scaffolding,’’ or the existing organization of their prior knowledge and experience, they define their own principles for learning, and then extrapolate from them to delineate action steps each participant wants to take to enhance his or her teaching and scholarship. In this model, observation is a vehicle to expose assumptions about learning, enabling participants to con- struct educational principles that will continue to guide their thinking and teaching.

프로그램의 핵심 중 하나는 각 참여자들이 개인의 흥미와 자신이 속한 기관의 교육과정의 니즈에 맞는 프로젝트를 수행한다는 것이다. 이러한 프로젝트는 전체 교육과정 revision부터 교수개발 프로그램 만들기까지 다양하다. 프로젝트를 개발하기 휘해서 참여자들은 프로그램 교수 및 공식 자문단과 link하는데, 공식 자문단은 프로그램의 동료 중 일부이며, 각 멤버의 프로젝트에 대하여 전략을 검톹하고 프로그램에서 얻은 인사이트를 제공한다. 자문 프로세스는 프로젝트의 구성요소를 명확히 하는 과정인데, 여기에는 다음이 포함된다.

One cornerstone of the program is each participant’s pursuit of a signifi- cant, focused project that matches the individual’s interests and addresses the curricular needs and conditions at his or her home institution. Such projects range from the revision of an entire medical school’s curriculum to the formulation of a faculty development program within a department. To de- velop their projects, participants link to program faculty members and a formal consultation group, a subset of their peers in the program who intensively confer on each member’s project by testing strategies and insights gained from the program. The consultative process seeks to clarify the project elements, including

• the definition of goals,

• institutional problem to be addressed,

• the role of stakeholders,

• barriers to implementation,

• required resources and

• evaluation method to determine measures of improvement.

프로젝트 그룹은 보통 4~5명의 참여자와 퍼실리테이터(1의사, 1교육자)로 구성되는데, 각 그룹은 2시간씩 5번, 2번씩 4번 만난다.

The project groups typically consist of four to five participants with faculty facilitators (one physician and one educator). Each group meets for five two-hour sessions in winter and four two-hour sessions in the spring block.

매년 프로그램은 참가자의 숫자를 35명으로 제한하여, 국제 지원자들 중 선발하고 그 중 일부는 HMS 교수를 포함시킨다. 이 선발과정은 경쟁이 치열한데, 다음을 기준으로 선발한다.

Each year, the program was limited to 35 individuals who were selected from an extensive international pool of applicants, with a small number of spaces held for HMS faculty members. Competitive selection was based on

• 지원자의 헌신 evidence of the applicant’s commit-ment to medical education,

• 프로젝트의 강점merits perceived merits of the proposed project, and

• 상관/과장의 지원 the commitment of the applicant’s chair-person or immediate superior to support that prospective project. 

방법

METHOD

다음의 성과는 측정

Outcomes that we sought to measure as a validation of the program were concentrated in three areas:

• 개인의 교육행동, 전문성행동 변화 individual changes in teaching behaviors and pro-fessional activities,

• 프로그램이 참가자와 소속기관에 갖는 효과에 대한 인식 the participants’perceptions of the effects those changes had had on them and their home de-partments or institutions, and

• 더 넓은 의학교육자 네트워크에 참여 the in-volvement of the participants in a wider network of medical educators.

 

• 개인의 변화 Individ-ual change was defined as

• self-reported changes in teaching behaviors,

• aca-demic productivity,

• academic advance-ment, and

• a renewed sense of commitment or identity as an educator.

• 소속기관에 대한 효과 Effect on home departments or institu-tions was defined in terms of

• the parti-cipants’ changes in teaching behaviors,

• involvement in educational committees and as consultants, as well as

• obtaining grant funding.

• 더 넓은 실천공동체에 참여 Participation in develop-ment and maintenance of a wider‘‘community of practice’’ was measured in terms of both

• maintaining ties to program participants and/or

• faculty members and outreach to others. 

RESULTS

고찰

DISCUSSION

참여자들의 impassioned testimonials로 보건대, 명백하게 이 프로그램의 접근법과 교육디자인이 중요한 요소였으며, 그들의 교육자로서의 정체성에 중요한 부분이었다. 프로그램은 참여자들이 자신이 되고자 하는 teacher의 모습을 명확히 하도록 도와줬으며, 그렇게 행동할 수 있는 전략을 제공하였다.

The approach to and the design of teaching were clearly important ele-ments of this program for respondents,and, judging by their impassioned testimonials, constituted an equally important part of their identities as educators. The program helps partic-ipants to clarify the kinds of teachers they want to be, and offers them strate-gies to implement those behaviors.

응답자들은 학습자들에게 더 민감해졌으며, 그들이 겪는 어려움에 더 잘 반응할 수 있게 되었다고 했다. 또한 학습자의 교우에 따라 교육내용과 스타일을 바꿀 수 있게 되었으며, 학습자들이 새로운 이해의 길을 따라가면서 어디쯤에 있는가를 이해하기 위한 behavior를 사용할 수 있게 되었고, 여기에는 progress of learning에 대한 감각을 발전시키기 위한 더 많은 상호작용성interactivity를 포함하였다. 프로그램 참여 2년 후, 응답자들은 프로그램에서 습득한 가치와 교육원칙을 실천으로 옮기고 있었다.

Respondents reported becoming more sensitive about and responsive to the struggles and problems of learners,attempting to adjust both content and style to their needs, adopting more behaviors to understand where learners are along the path to new understand-ing, and including more interactivity to have a better sense of the progress of learning. Two years following their participation in the program, respond-ents had translated the values and educational principles taken from the program into practice. 

 

개별화된 자문과 집중펠로우십이 효과가 있음

Enhancements highlighted by the respondents included changes in their own approaches to teaching. These results confirm others’ findings that individualized consultation and inten-sive fellowships are effective strategies for changing teachers’ behaviors.13

 

CME에 대해서 3~4개의 교육전략을 병합한 인터벤션 중 약 80%가 긍정적인 변화를 만들어내며, 컨퍼런스와 같은 전통적인 방식의 짧은(하루 혹은 이하) 공식적 CME event 는 거의 변화를 만들지 못한다.

Our findings also confirm Davis’ meta-analysis of studies on continuing med-ical education (CME), which found that nearly 80% of the interventions that combined three or more educa-tional strategies were most likely to demonstrate positive changes, whereas the ‘‘traditional cluster of relatively short (one day or less) formal CME events such as conferences generally generated no change.’’14

 

의사-교육자는 더 나은 세상을 만들고자 하는 열망과 관련된 내면의underlying 가치관을 가지고 있으며, 동료와 학습자로부터 생명력vitality을 얻는다.

Our study also counters the traditional lore that few physicians can or will create time for an intensive experience, and instead, con-firms recent findings that physician–educators may hold an underlying set of values associated with a desire to make the world better, and gain vitality from both colleagues and learners.15

이번 연구에서 가장 흥미롭고 중요한 결과 중 하나는 비공식적 학습 네트워크의 도입니다. 참여자들은 자신의 흥미를 지속시키기 위하여 이러한 네트워크를 만들었으며, 참여자들이 "실천공동체"를 만듦으로써 자기 자신에 대한 인식과 교육자로서의 수행능력에 변화를 만들어내는 것이 가능함을 보여준다. 실천공동체는 더 발전된 이미지와 스킬을 support하고, 지속적으로 프로그램에 에너지를 준다.

One of the most interesting and important findings of our study has been the implementation of informal learning networks that participants have created to sustain their interest, both across disciplines and across institutions, as a result of their participation in the program. The maintenance of these networks and the value that participants place on them suggest that these participants created a ‘‘community of practice’’ that makes change possible in the way they perceive themselves and perform as educators. The community of practice continues the conversation for individuals to support further develop-ment of image and skills, and to continue the energy initiated in the program. 

기관 차원의 변화는 프로그램 참여자들이 자신의 기관에 "씨앗을 뿌렸seeding"기 때문에 가능했던 것으로 보인다.

Beyond the individual effectiveness and empowerment that respondents reported, institutional changes appear to emanate from the ‘‘seeding’’ of program participants at medical schools and academic medical centers across the country and the globe

왜 성공적이었을까?

Why is this professional development program successful? 

• 분절화된 스킬에 집중하거나 전통적인 교육방식을 사용하지 않았다. 프로그램에서는 의사들이 교육자로서 자신을 바라보는 감각을 근본적으로 바꾸고자 했다.
  It is clearly different from the majority of traditional faculty development programs, in that it does not address the development of discrete skills (e.g., use of PowerPoint or how to stimulate more questions), nor does it use the more traditional format of brief activities and sessions. Instead, the Harvard Macy Program for Physician Educators seeks to fundamentally alter physicians’ sense of themselves as educators. To accomplish that, this program is much longer than most CME courses, giving participants time to become immersed in new ideas. 
• 이해하고, 성찰하고, 내면화하고, 도입하기 위한 시간과 공간을 충분히 제공. 다양한 서로 연결된 아이디어와 스킬에 집중적으로 노출되게 함.
  Second, a session separated in time from the first, allows participants time and space to digest, reflect, ‘‘try out’’ new ideas and skills, and have any changes reinforced in the second session, enabling participants to internalize and adopt them. It uses intensive exposure to a variety of intertwined ideas and skills simultaneously to accomplish that goal. 
• 학습은 사회적, 전환적 프로세스라는 기본 가정을 Professional development 활동으로 translate시켰다. 상호작용과 피드백이 강조되고, 자신의 가정을 점검하고 익숙했던 것을 낯설게 하였다.
  Third, the effectiveness of this program results from the translation of its basic assumptions about learning as a social and transformative process into a professional development experiment or activity characterized by extensive interaction and feedback from colleagues as both teachers and fellow learners. The program’s learning formats enable participants to make explicit and test their personal assumptions, and to work from the familiar to the unfamiliar, with faculty members facilitating a process to make new ideas meaningful.17 
• 자신이 속한 환경의 제약 속에서 새로운 아이디어의 적용가능성을 점검하게끔 하였다.
  Fourth, substantial work on a project and other activities pushes for testing the applicability of a new way of thinking within the constraints of each participant’s home environment. 
• 자신만의 실천공동체를 형성하였다.
  Finally, the participants’ creation of their own community of practice sustains ongoing work with a group of like-minded individuals.

 

---

Acad Med. 2003 Jul;78(7):702-8.

Transformative professional development of physicians as educators: assessment of a model.

Armstrong EG1, Doyle J, Bennett NL.

Author information

• 1Harvard-Macy Institute, Harvard Medical School, 1135 Tremont Street, Suite 900, Boston, MA 02120, USA. elizabeth_armstrong@hms.harvard.edu

Abstract

PURPOSE:

Medical education reform has been the clarion call of U.S. medical educators and policymakers for two decades. To foster change and seed reform, Harvard Medical School created a professional development program for physicians and scientists actively engaged in educating futurephysicians that sought to transform both participants and their schools. This study focused on identifying the long-term effects of a professionaldevelopment program on physician educators.

METHOD:

A follow-up survey of the 1995-97 cohorts of the Harvard Macy Program for Physician Educators was conducted by sending the 99 program participants a questionnaire two years after their participation. Main outcome measures studied were individual changes as reflected in participants' self-reported shifts in teaching behaviors, academic productivity, career advancement, and sense of commitment.

RESULTS:

A total of 63 participants completed the questionnaire, for a response rate of 63.6%. Two years following participation in the program, a majority (88.8%) of respondents reported that participation had significantly affected their professional development, including long-term changes in teaching behaviors (77.8%), engagement in new educational activities from committee work (86%) to grant funding (52.4%), and renewed vitality/identification of themselves as educators.

CONCLUSIONS:

Long-term follow-up of participants enrolled in an intensive program for physician educators suggests that professionaldevelopment programs that create an immersion experience designed in a high-challenge, high-support environment, emphasizing experiential and participatory activities can change behaviors in significant ways, and that these changes endure over time.

PMID:

 

12857688

 

[PubMed - indexed for MEDLINE]