“Continuity” as an Organizing Principle for Clinical Education Reform

David A. Hirsh, M.D., Barbara Ogur, M.D., George E. Thibault, M.D., and Malcolm Cox, M.D.

의학교육의 궁극적인 목적 - 건강에 대한 사회적 요구 달성 - 을 위해서 학부의학교육은 모든 의학 분야를 망라하여 핵심역량에 대하여 폭넓게 숙련된 학생을 양성하는 것이다. 고도로 전문화되고 생산성을 높일 것이 요구되어 교육이 한정된 자원을 놓고 연구와 진료와 같은 다른 영역과 경쟁을 해야 하는 환경에서 어떻게 이 목표를 달성할 것인지는 중요한 도전과제라 할 수 있다.

If the ultimate purpose of medical education —to meet the health needs of society — is to be achieved, the primary goal of undergraduate medical education should be to produce students who are broadly skilled in the core competencies that transcend all disciplines of medicine.1,2 The challenge is how to accomplish this goal in a clinical learning environment fragmented by increasing specialization and demands for clinical productivity and constrained by a prevailing culture in which education must compete with research and clinical practice for medical school resources.3

의과학과 진료의 발전은 눈부신데, 미국 의과대학의 임상교육 모델은 William Osler가 살던 백년 전과 비교했을 때 거의 달라진게 없다. 학생들은 급성기 병원의 특정 전공과에 배치되어 랜덤한 순서로 짧은 로테이션을 돌게 된다. 그리고 그 속에서 학생이 겪게 되는 임상경험역시 Osler의 시대와 다를게 별로 없다.

As compared with the dramatic changes that have occurred in biomedical science and the practice of medicine, the fundamental model of clinical education in American medical schools has changed little since the time of Sir William Osler, a century ago. Students are still assigned to specialty-specific teams of interns, residents, and supervising faculty physicians for relatively brief, randomly sequenced rotations in acute care hospitals. 4,5 And the core clinical credentialing experience continues to be this same series of rotations, primarily in the third year of the traditional four-year undergraduate curriculum, just as it was in Osler’s day.

학생들은 졸업 후 수련과정에서 최소 3년, 길게는 8년 이상을 병원에서 보내게 될 것이며, 이 시기에 필요한 기술들을 연마하기에 병원이라는 환경이 학습 기회를 제공하는 측면에서는 부족함이 없으나, 현재의 모델은 미래사회의 요구와 변화를 전혀 따라가지 못하고 있다. 이를 인지한 많은 사람들은 현재의 급성기 임상교육 모델의 강점을 유지하면서, 현 모델이 가진 주요한 한계점인 '서로 다른 학습경험 사이의 연계성과 연속성'을 극복하기 위한 임상교육의 새로운 모델을 요구하기에 나섰다.

Although there is no doubt that the hospital environment remains rich in learning opportunities for medical students and that students need to learn the skills necessary to succeed in an environment in which most of them will spend 3 to 8 years of postgraduate training, there is a growing sense nationally that the current model is poorly aligned with society’s present and future health care needs.6,7 This realization has led many observers to call for a new model of clinical education, one that would incorporate the strengths of the present acute care educational model but eliminate the model’s major weakness — a lack of connection or continuity among different learning experiences.8,9

교육적 연속성

educational continuity

수련중인 의사에게 있어서, 근대 학습 이론에 기반을 둔 '교육의 연속성'이란, 전문직으로서 그리고 한 개인으로서 지속적인 발전에 대한 것이기도 하다. 교육과정의 한 부분이 아니라, 전체 교육과정에 대한 'ownership'을 갖는 것이 '교육적 연속성'의 필수조건이라고 할 수 있다.

Rooted in the principles of modern learning theory,10,11 the notion of educational continuity reflects the progressive professional and personal development required of physicians in training.12 A spirit of “ownership” of the entire curriculum, rather than one discipline-specific portion of the curriculum, is a prerequisite for educational continuity.13

Continuity of Care

언제나 가장 강력한 동기유발요인은 환자에게 헌신하는 마음가짐이었다. 봉사학습(service learning programs)에서는 학생들이 자신의 열망을 이룰 수 있게 하는 것이 가장 강력하게 학습을 지지하는 것이었으나, 임상실습경험 그 자체에서는 막상 이것을 거의 활용하지 않고 있었다.

Throughout the history of the profession, the most powerful motivator for learning has been the sense of deep commitment to patients. Connecting the student’s desire to serve with his or her desire to learn has strong support in learning theory and has been used effectively for many years in a wide variety of service learning programs in health-related disciplines. However, only rarely has service learning been part of the core clerkship experience itself.14

Continuity of Curriculum

학습자의 가치관/태도/지식/술기 등이 향상되도록 하기 위해서는, 교육과정의 각 요소들이 서로 논리적인 연결구조를 가지고 있어야 한다. 이러한 교육과정의 특징은 세 가지로 요약할 수 있다.

To support the progression of a learner’s values, attitudes, knowledge, and skills, each component of a curriculum should have a rational, considered relationship with all others. A developmentally progressive curriculum has three major aspects. 

First, there is a rational sequential order that facilitates learning, with certain types of knowledge and skills serving as the foundation for subsequent learning. Skills that are notably different, but equally complex, may still be most appropriately taught in a particular order. For example, knowledge of anatomy and pathophysiology facilitates the taking of a medical history. 

Second, more complex tasks should follow some degree of achievement in the performance of more simple but related tasks. Thus, one learns to construct a simple problem list before learning to develop a complicated differential diagnosis. Similarly, grappling with complex therapeutic decisions makes little sense for a student who has yet to master rudimentary diagnostic decision making. 

Third, the curriculum should be implemented in a learner-centered manner, such that a given student’s learning is tailored to his or her particular evolving (i.e., developmentally appropriate) needs.

Continuity of Supervision

교수와 학생간, 그리고 여러 교수들간 연계성을 확립하는 것이 중요하다. 학생들은 지속적으로 지도를 해주는 사람에 대해 환자진료에 대해서 공동의 책임을 갖는다는 직업적인 친밀감을 갖게 된다. 

Establishing connections between faculty, other caregivers, and students and among faculty across disciplines is critical to forming a productive learning community.16 Students and longitudinal preceptors share the professional intimacy of dual responsibility for patient care. Such relationships in which faculty members have personal responsibility for overseeing their own students, provide students with the emotional comfort to take intellectual risks in their learning. At the same time, trusting relationships and shared goals foster coaching, promote effective feedback, and enhance clinical performance.

장애물

barriers to educational continuity

'교육적 연속성'의 개념이 임상교육 개혁에 있어서 핵심 원칙이긴 하지만, 그 장애물 또한 만만치 않다. 

Although the concept of educational continuity provides a powerful organizing principle for clinical education reform, the barriers to changing the manner in which the traditional core clinical clerkship experience is organized should not be underestimated (Table 2). Promoting innovation on the basis of either educational theory or nascent outcomes data alone will require visionary leadership, innovative resource management, and careful attention to learning, cultural, and regulatory issues.

새로운 모델

new models of clinical clerkships

A부터 I까지 각각의 모델과 예시에 대한 설명

Promoting educational continuity is complicated by the traditional division of the core clinical clerkship experience into a disconnected series of independently governed, discipline-specific, randomly ordered, sequential blocks (Fig. 1A), each characterized by largely ad hoc patient assignments and poorly coordinated learning objectives. To provide opportunities for a more collective approach to curriculum design and management and to better deal with so-called orphan topics, medical schools have begun to assume more centralized control of the clerkship year. Over the past decade, this shift in governance has allowed for the development of a variety of new models of clinical clerkships, many of which have incorporated elements of educational continuity into the overall learning experience. 

Some schools have developed interdisciplinary “intersessions” or “interclerkships” (courses, generally of about a week’s duration, interposed between sequential clerkships) (Fig. 1B)19 and longitudinal “themes” or “threads” (courses that link similar content between clerkships) (Fig. 1C).20 Both models provide opportunities for interdisciplinary curriculum design and management. However, short of major curricular revisions (such as consolidating core clerkship objectives or extending the duration of the overall experience), time limitations curtail the ability of either approach to reach its full potential. Many of these new clerkship experiences have used small-group, problem-based learning, which although a natural locus for interdisciplinary teaching,21 had not previously been used in the clinical curriculum as commonly as in the preclinical curriculum.22 

예시) In England, at the University of Manchester, modules of thematically organized, problem-based material are now being taught alongside traditional discipline-specific “attachments” (clerkships).23 Semistructured interviews of Manchester graduates have indicated significant gains in dealing with clinical uncertainty, knowing their personal limits, and asking for help when these limits are exceeded.24 

예시) A variant of problem-based learning has been used at the University of Dundee in Scotland to integrate content across the entire curriculum.25 Task-based learning uses the clinical experience itself, rather than “paper” cases, to generate examples of a series of predetermined tasks, with the students themselves responsible for finding opportunities to explore these tasks as they move through a discipline-specific, sequential curriculum. Task-based learning is credited with enhancing the transfer of basic science knowledge to the clinical years as well as providing an opportunity for integration of core content across clinical disciplines without the need to create interdisciplinary teaching teams.26

Where curricular content sufficiently overlaps disciplines (neurology and psychiatry or obstetrics and neonatology, for example), the opportunity exists to integrate clerkships more fully across disciplinary lines (Fig. 1D). However, although there are examples of integration in which related clerkships have been grouped together for administrative or scheduling purposes, multidisciplinary governance and joint teaching have been attempted only infrequently and have proved difficult to sustain in a subspecialty-dominant practice environment.27-29

Ambulatory care clerkships are another potential locus for interdisciplinary design and management. In recent years, block or longitudinal ambulatory care clerkships (Fig. 1E and 1F, respectively) — individually or collectively organized by departments of family medicine, general internal medicine, and general pediatrics — have become relatively common components of the core clerkship year.30-34 Although single or isolated block experiences are an appropriate forum for the follow-up of time-limited disorders, they provide little opportunity for exposure to chronic disease management, a major required competency in the modern practice environment. 

Students appear to benefit from longitudinal ambulatory care experiences by developing more effective relationships with patients, gaining insight into the psychosocial aspects of care, and understanding the longitudinal management of chronic illness.35 However, this potential is often degraded by competing inpatient responsibilities and patient-scheduling problems. Recurring ambulatory- block rotations devoted exclusively to generalist community practice, alternating with discipline-specific inpatient blocks (Fig. 1G), might provide an effective solution. Combining both departmentally based and interdisciplinary governance models, this intriguing approach — recently suggested to promote continuity in internal medicine residency education36 — has yet to be tested. Applied to undergraduate education, however, it would probably require substantial lengthening of the traditional clerkship year. 

Many permutations of these basic models are possible. Any substantial combination of sequential and longitudinal experiences — so-called mixed models — would allow for some degree of both discipline-specific immersion and educational continuity (Fig. 1H). 

예시) In a pilot program at Case Western Reserve University in Cleveland, for example, time was equally divided between traditional, discipline-specific inpatient rotations and ambulatory settings, with ambulatory training being provided in specialty clinics and a yearlong continuity experience in one of the generalist disciplines.37 Weekly tutorials and seminars, organized as longitudinal themes and provided by a constant group of faculty mentors, served to bridge individual specialty-specific experiences. Grade distributions in core clerkships were similar, except in psychiatry, in which students in the integrated track achieved significantly higher scores than did students in the traditional curriculum. They also performed better on a generalist Objective Structured Clinical Examination but had a lower mean score on the National Board of Medical Examiners’ internal-medicine “shelf” exam. A majority of students reported that they would choose the integrated third year again and would recommend it to others. 

예시) Similar approaches are being tested at several teaching hospitals associated with Harvard Medical School and the University of California, San Francisco, as part of school-wide efforts on medical education reform. 

Longitudinal organization of most or all specialties that are commonly represented in the core clerkships (Fig. 1I) is an emerging but still uncommon model. 

예시) Motivated by the need for graduates who are interested in practicing in medically underserved areas, some schools have created clerkships that place students in longitudinal ambulatory care experiences — including primary care and multidisciplinary group practices — for a significant portion of their clinical training. When measured against regional workforce goals, these programs have been judged to be quite successful. 38-43 Students in these variously integrated longitudinal clerkships have performed as well as their more traditionally trained counterparts on local and national examinations of clinical competence.44-46

예시) Other schools are testing the feasibility of multidisciplinary, cross-site longitudinal integration without emphasizing primary care or attempting to steer students toward the generalist disciplines. In a pilot project at Harvard Medical School and the Cambridge Health Alliance in Cambridge, Massachusetts, students spend the entire third year learning from serial contact with a carefully selected cohort of patients recruited from their preceptors’ practices in internal medicine, pediatrics, psychiatry, neurology, and obstetrics and gynecology.47 Each patient is followed across all venues of care, including outpatient specialty and subspecialty clinics, the inpatient setting, and rehabilitative, nursing home, and home care. Special arrangements facilitate exposure to patients in the emergency department and a full spectrum of general surgical care. Weekly case-based tutorials on fundamental topics that seek to integrate basic and clinical science, simulation exercises, electronic records, and mentored educational portfolios further emphasize the interdisciplinary and personalized nature of the curriculum.48,49

결론

conclusions

새로운 임상실습 모델이 지속될 가치가 있는지 아니면 또 다른 모델이 등장할 것인지는 두고 볼 일이다. 그러나 모델이 무엇이든 임상교육 환경은 좀 더 전문가로서의 발달을 강조하고 환자 중심의 학습을 받아들어야 할 필요가 있다. 보건의료의 궁극적인 목적이 환자중심의 진료와 의료의 질 향상인 것처럼, 교육시스템에서는 학습자중심의 교육과 교육의 질 향상이 그 핵심이라 할 것이다.

Only time will tell whether any of these new clerkship models will have enduring value or whether yet others will need to emerge. Whatever the model, the clinical environment must be made more receptive to professional development, and learning must be embedded in caring for patients. Just as patient-centeredness and improvements in health care quality are becoming the overarching metrics of the health care delivery system, so too should learner-centeredness and improvements in educational quality become the proximate metrics of the medical education system.

"Continuity" as an organizing principle for clinical education reform.

International Track in Medicine 

• Maastricht 의과대학에서는 네덜란드의 의사가 점차 다양한 문화적 배경의, 다양한 언어를 구사하는 환자들을 만나게 되고, 네덜란드 이외의 국가에서 발생하는 질병까지도 다루게 되는 환경의 변화(세계화, 국제화)에 대비하여 ITM이라는 프로그램을 시작함.
• 이 프로그램은 2011년부터 시작되었으며 매년 60~80명 정도(전체정원 350명)를 선발하는 소규모 Bachelor program으로 영어로 진행함.
  
• 아래는 이 ITM 과목 학생들에 대한 교육 및 시험에 대한 규칙이다.

Education and Examination Rules,

International Track in Medicine (ITM) for numerus fixus students, Curriculum 2011, academic year 2013-2014

CONTENTS:

PARAGRAPH 1- GENERAL...................................................................................... 4

Article 1.1 – Scope of the rules.................................................................................. 4

Article 1.2 – Definitions............................................................................................ 4

Article 1.3 – Objectives and learning outcomes of the ITM...................................... 5

Article 1.4 – Format ITM: Full time, language and study counselling...................... 5

Article 1.5 – Study load............................................................................................. 5

Article 1.6 – Study advice......................................................................................... 5

Article 1.7 – Awarding credits.................................................................................. 5

    Article 1.8 – Fraud…………….……………………………………...……………..5

PARAGRAPH 2 – GENERAL PROVISIONS CONCERNING EXAMINATIONS AND RESITS          6

Article 2.1 – Block examination................................................................................ 6

Article 2.2 –  OSCE (Objective Structured Clinical Examination)/Skills examination       6

Article 2.3 – Progress examination............................................................................ 6

Article 2.4 - Professional behaviour........................................................................... 6

Article 2.5 – Portfolio examination............................................................................ 6

Article 2.6– Consultation skills and Reflection programme(CORE)…...……....…..8 Article 2.7 – Non-block related assignments.....................................................…....8
Article 2.8 –Examination format……………………………………………….......8

Article 2.9 –  Examination results............................................................................. 8

Article 2.10 – Grading and publication of examination results................................. 9

Article 2.11  - Right of inspection............................................................................ 9

Article 2.12 – Validity of the examinations and components of examinations......... 9

Article 2.13 – Exemption from examinations............................................................ 9

Article 2.14 - Resits....................................................................................................9                      

PARAGRAPH 3 – COURSE YEAR 1 ITM……………..

Article 3 – Study programme and examination programme of course year 1 ITM... 9

PARAGRAPH 4 – COURSE YEAR 2 ITM.............................................................. 10

Article 4.1 - Admission............................................................................................ 10

Article 4.2 –Study  and examination programme course year 2 ITM ................... 10

PARAGRAPH 5 – COURSE YEAR 3 ITM.............................................................. 10

Article 5.1 – Admission .......................................................................................... 10

Article 5.2 – Study and examination programme of course year 3 ITM................. 11

PARAGRAPH 6 – Reserved for later provisions....................................................... 11

PARAGRAPH 7 – EXAMINATIONS………………...............……………....….....11

Article 7 – Examinations in the ITM………………………………………………………………………………..11

Article 7.1 - Final examination…………………………………………………....11

Article 7.2 - Flexible bachelor's programme and examination for the flexible   bachelor's programme................................................................................................................11

Article 7.3 - Degree..................................................................................................12

PARAGRAAF 8 – PREVIOUS EDUCATION........................................................ 12

    Article 8.1 – Further previous education requirements (profiles)

    Article 8.2 – Colloquium Doctum (Entrance examination)

    Article 8.3 – Previous education for students with non-Dutch diplomas

    Article 8.4 – vervallen

PARAGRAPH 9 – SERIOUS PROBLEMS REGARDING PROFESSIONAL BEHAVIOUR AND UNSUITABILITY (IUDICIUM ABEUNDI)………………………...........................................................……………13

Article 9.1 – Professional behaviour and performance in the programme including patient care...............................................................................................................13
Article 9.2 – Unsuitability (Iudicium abeundi)........................................................13

PARAGRAPH 10 – LEGAL PROTECTION…………………...……………….......13

Article 10 – Right of appeal………………..……………………………..…...….13

PARAGRAPH 11 – FINAL PROVISIONS.............................................................. 13

Article 11.1 - Amendments...................................................................................... 13

Article 11.2 – Publication........................................................................................ 13

Article 11.3 – Unforeseen circumstances................................................................. 14

Article 11.4 – Hardship clause................................................................................. 14

Article 11.5 – Official title……………………………………....………...……....14

Article 11.6 – Date of commencement…………………………....……………….14

PARAGRAPH 1- GENERAL

적용범위 Article 1.1 – Scope of the rules

1. Students may choose for the International Track in medicine for numerus fixus students, curriculum 2011. These rules apply to all students registered for the academic year 2013-2014 of the International Track in Medicine for numerus fixus students, curriculum 2011 (hereinafter referred to as ITM).

2. The ITM is offered within the Faculty of Health, Medicine and Life Sciences (hereinafter referred to as FHML) of Maastricht University (hereinafter referred to as UM).

각 용어에 대한 정의 Article 1.2 – Definitions

In these rules the following definitions apply:

- Academic year: the time period starting on 1 September and ending on 31 August of the subsequent calendar year.

- Block: theme-based study unit in the first or second course year.

- Block examination: the aggregate of partial assessments throughout the block programme, including the end test.

- Combination table: a table that is determined for each academic year by the Examination Board of Medicine and that shows the rules of combination which will be used to combine the marks a student receives in the progress tests throughout the course year to establish the result of the progress examination for the pertinent course year.

- Competency domains: the various roles present in the professional performance of a doctor as mentioned in the Dutch Blueprint (Raamplan).

- Counsellor: tutor at the Student Counselling Service responsible for general and specific tasks with regards to study advice for all students.

- Course year: Year 1, 2 or 3 of the ITM, offering a further detailed programme.

- Credit: a unit equal to one ECTS credit with a study load of 28 hours.

- ECTS: European Credit Transfer System.

- EleUM: Electronic learning environment of Maastricht University.

- End test: the test that, as part of the block examination, is taken at the end of the respective study unit.

- Examination: an examination is a component of the total examination. An examination may consist of several components/tests: these are weighted in a certain way to lead to one final result.

- Examination Board of Medicine (EC – Examencommissie Geneeskunde): the committee as established to administer the examinations and to execute the organisation and coordination of the examinations.

- Examiner: person appointed by the Examination Board of Medicine to conduct examinations

- Medicine Management Team: the central consultation body medicine within the FHML Institute for Education and tailor-made programmes.

- Mentor: tutor in charge of tasks related to study supervision and the portfolios of individual students.

- OSCE: objective structured clinical examination, being an examination, is a series of simulated clinical situations during which the medical skills and knowledge of students are tested in an integral fashion.

- Portfolio: the portfolio consists of documentation, administrated by the student, of the student’s professional and academic development.

- Portfolio review committee: committee as referred to in the relevant article of the Rules and Regulations

- Practical exercise: the exercise, as follows participation in a practical educational activity, geared towards attaining certain skills, knowledge and insight.

- Practical Medical Training (PMT): programme aimed at teaching knowledge and skills (skills training courses) which are important to exercise the medical profession and including periods in which the student does a practical internship in the health care service.

-Propedeutic phase: the first period of the ITM that corresponds with course year 1. The propedeutic phase of the ITM has no propedeutic examination.

- Raamplan: the Dutch Blueprint for the national curriculum for medical schools as decreed by the Dean’s Council of Medical Sciences, containing the learning outcomes for the education of medical doctors in the Netherlands.

- Rules and Regulations: the regulations to be specified by the Examination Board of Medicine regarding a smooth course of events during examinations and concerning any measures to be taken in that respect, and the guidelines and instructions to examiners regarding the assessment of the persons taking the examination and about determining the results of the examination.

- Skills examination: the skills examination consists of a variety of assessments throughout the year. Each assessment will result in feedback and/or a result that has to be included in the student’s portfolio. The final result of the skills examination will be based on aggregation / combination of all relevant assessment results – as specified in the assessment plan.
- Study portfolio: the portfolio managed by the chair of the Examination Board of Medicine, concerning the study results of the student, as detailed in articles 4.1 to 4.4 of the Rules and Regulations.

- Table of norms: a table presenting the norms put to use in the progress tests. The table of norms is calculated after the test has been taken, and added to EleUM.

- Test: a part of an examination. 

- Tutor: person who supervises students in the study groups of year 1 and 2.
- WHW: Wet op het Hoger onderwijs en Wetenschappelijk onderzoek (Higher Education and Scientific Research Act).

ITM의 목표/학습성과 Article 1.3 – Objectives and learning outcomes of the ITM

1. The objective of the ITM is to impart knowledge, insight and skills in the field of Medicine so they can meet the requirements of the Dutch Blueprint.

3. For the students of the International Track in Medicine (for numerus fixus students) - who wants to continue their education in Medicine- there is a master programme in Medicine at the FHML/UM: the “Reguliere, aansluitende masteropleiding Geneeskunde”.

ITM의 형식(시간, 언어, 지도) Article 1.4 – Format ITM: Full time, language and study counselling

1. The ITM is offered on a full-time basis.
2. The ITM is offered in the English language.
3. The Faculty ensures that the students registered for the programme receive adequate study counselling and guidance.

학습량(학점) Article 1.5 – Study load

The ITM has a study load of 180 credits, divided over three course years of 60 credits each.

학습 조언 Article 1.6 – Study advice : ITM을 계속 할지 말지에 대한 결정에 대한 조언.

1. The Examination Board of Medicine, acting on behalf of the board of the FHML, issues each student, no later than the end of the first year of the student’s registration for the first course year of the ITM, a study advice regarding the continuation of his or her study.

2. Without prejudice to the stipulation in the first section, the Examination Board of Medicine, on behalf of the FHML board, can issue the study advice to the student at any time he or she has not met the requirements to pass the first course year (with a combined study load of 60 credits).

학점 수여 Article 1.7 – Awarding credits

1. Credits are awarded as soon as the student has successfully completed the entire examination concerned.

2. For study taken abroad credits are only awarded if the programme was approved beforehand by the Examination Board of Medicine of the FHML.

사기(기만) Article 1.8 – Fraud : 표절을 포함한 사기(기만)행위는 그것을 '시도하는 것'까지도 포함함. 영구제명 가능.

1. Fraud, including plagiarism, is understood as a student’s act or failure to act that makes it partially or fully impossible to correctly assess his/her knowledge, insight and skills.

2. Plagiarism is understood as the presentation of one’s own or other people’s ideas or words without adequate reference to the source.
3. By fraud is also understood attempted fraud.

4. If the Examination Board of Medicine establishes that a student has committed fraud in an exam or exam component, it may impose suitable measures.

5. In serious cases of fraud, the Examination Board of Medicine can propose to the UM Executive Board that the student(s) concerned be permanently deregistered from the programme.

6. The General FHML-Regulation for Fraud, as drawn up by the Examination Boards, further details what is understood as fraud and what measures can be imposed by the Examination Board of Medicine.

PARAGRAPH 2 – GENERAL PROVISIONS CONCERNING EXAMINATIONS AND RESITS

블록과 클러스터 시험 Article 2.1 – Block and cluster examination

1. Each block and cluster has an examination. The examination can consist of several parts.

2. The content of each block or cluster is prescribed in a description that is posted on Eleum.

OSCE와 술기 시험Article 2.2 – OSCE (objective structural clinical examination)/SKILLS EXAMINATION

1. In course year 1 a skills examination is conducted. In course year 2 and 3 an OSCE is conducted.

진단 평가 Article 2.3 – Progress examination

1. In course year 1, 2 and 3 of the ITM a progress examination is administered to all students. It consists of four tests (test moments).

2. The Interuniversity Progress Test Review Committee determines the rules with regard to the format and content of the progress examination.

3. The progress examination can only be taken one time per academic year. If a student fails to pass the progress test in the first instance, the result of the progress test of the following year of study or the result of a number of progress tests specified by the Board of Examiners  is also counted as the resit test. The student still passes the progress test he failed initially if the student meets the examination requirements of the progress test(s) in question.
3.1 The results obtained in the progress tests are also an obligatory (mandatory) part of the portfolio described in article 2.5 of these rules. The student must include the results in the portfolio in their entirety and without alteration. The progress of the results will be discussed in the progress meetings with the mentor as referred to in article 2.5 of these rules.

전문직 다운 행동Article 2.4 - Professional behaviour
1. Course year 1, 2 and 3 of the ITM is concluded with an examination of professional behaviour, consisting of an assessment on the basis of (a.) the assessments of professional behaviour that are part of regular assessments as described in the Rules and Regulations article 2.4 and (b.) possible reports as meant in article 9(1) of these rules.


포트폴리오 평가 Article 2.5 – Portfolio examination

1               General

The portfolio is 학생이 작성kept up to date by the student and is used as the basis of all formal progress meetings between mentor and student.

2              The portfolio consists of 세 부분three parts: a dossier part, a reflection part and a progress part.(3~5는 각각의 파트에 대한 설명)

2.1          The dossier part contains all required information concerning the development of competencies prescribed and the results of all assessments.

2.2          The reflection part presents a strength-weakness analysis of the competency development.

2.3          The progress part includes a written report of the discussions between mentor and student during the progress meetings, approved by the mentor.

3              The student is responsible for the dossier part to contain sufficient information concerning all formal progress meetings as referred to in paragraph 5.1 of this article.

The dossier part contains at least everything that is available and up to date:

a. Results and assessments as mentioned in the examination regulations (toetsplannen) c.q. portfolio regulations;

b. Other results/assessments as agreed upon in meetings referred to in section 5.1 sub c; and

c. Any other evidence to demonstrate competency development as contributed by the student.

4            The reflection part contains strength-weakness analysis of the student.

The strength-weakness analyses comprise all four roles of the education and examination programme. These roles (competencies) are: role as medical expert, role as scientist, role as a healthcare worker, and role as a person. The strength-weakness analyses need to be updated after each progress meeting.

4.1           The reflection part is always supported by concrete evidence from the file section.

4.2          The reflection part contains concrete learning goals for the time period until the next progress meeting.

5            The progress part contains reports of all formal progress meetings between mentor and student

5.1            The meetings referred to in section 5 have at least the following three points on the           agenda:

a. Retrospection: looking back on earlier agreements reviewing if and how they have been realised.

b. Evaluation and analysis: discussing how everything is going and why.

c. Planning further actions, meetings and agreements: determining for example the planning of the next meeting, the attendance of any extra or remediation education parts/modules, additional examinations or information gathering.

6               Progress meetings : Student and mentor will have several formal progress meetings in year 1, 2 and 3.

6.1          The student will take minutes (notes) of the content of each meeting and present them to the mentor for approval, after which they are included in the progress section of the portfolio.

7               멘토의 조언자적 역할 Advising role of the mentors

7.1          At the end of each study year, the mentor will issue a formal advice regarding the student’s academic progress and competency development on the basis of the portfolio kept by the student, in relation to the learning outcomes of the ITM. This advice is presented to the group of mentors of the relevant year group.

7.2          The advice referred to in section 1 is issued in the last planned meeting between mentor and student, is discussed and is put in writing.

7.3          The advice as referred to in section 1 is in line with the assessments as recorded during the meetings, if these were held in conformity with the regulations that apply as listed in aforementioned sections of this article 5.

8             일년 단위 그룹에 대한 포트폴리오 평가  The portfolio assessment procedure per year group

8.1          The group of mentors of the relevant year group issues a final advice on the basis of the advice of the mentor and the portfolio, in which the mentor concerned has no say.

8.2          An independent assessment committee consisting of 2 members (not mentors) makes a recommendation – on the basis of the portfolio of the student and the final advice issued by the mentor group - to either award or not award the study credits associated with the portfolio of the relevant year group to the Examination Board of Medicine.

8.3          If the recommendation as referred to in section 2 is negative, and is accepted by the Examination Board of Medicine, the student will have to follow a remediation programme.

8.4          If the remediation programme as mentioned in section 3 has not led to the required competency development, the student will not be admitted to the next course year, unless decided otherwise by the Examination Board of Medicine.

9               학생/멘토를 바꿀 권리 Right to choose another student/mentor

If there is an irreconcilable difference of character between mentor and student they are both at liberty to request a different combination. The request will be reviewed by the Examination Board of Medicine.

10            second opinion을 제시할 권리  Right to a second opinion

In the case of a difference of opinion, the student and the mentor both have a right to a second opinion by an expert third party, to be appointed by both.

11            포트폴리오의 진실성  Authenticity of portfolio material

By including materials in the portfolio the student is implying by default that this is authentic own material.

상담/성찰 Article 2.6 – Consultation skills and Reflection programme (CORE)

1. Course year 1, 2 and 3 provides a CORE programme.

블록 비관련 과제 Article 2.7 – Non-block-related assignments

1. Course year 1, 2 and 3 has some non-block-related assignments, which extend in time over multiple blocks. These interdisciplinary assignments are included in the provisions in these rules for course year 1, 2 and 3.

시험의 형식 Article 2.8 –Examination format

1. The Examination Board of Medicine determines if examinations are conducted in written, oral or other form.

2. Examinations are carried out in the English language.

장애가 있는 학생에 대한 조항

3. For students with disabilities, arrangements can be made, once a request to this effect has been submitted, to take examinations in a manner adapted to accommodate their individual disability, in so far as reasonably possible in view of the objective of the study programme and the educational and organisational provisions.

Where necessary the Examination Board of Medicine will seek expert advice before making their decision.

4. The oral examination is public, unless the Examination Board of Medicine decrees otherwise in a special case or the student objects to this.

5. The Examination Board of Medicine specifies, at the suggestion of the examiners as mentioned in article 2.1 – 2.7 written examination regulations and resit regulations. These regulations describe the format and content of the tests and resit tests, the timetable of the testing, the appropriate pass/fail scores and the method for determining the results of the test. These regulations are included on Eleum.

시험 결과 Article 2.9 – Examination results

1. The result of the examination will be qualified as decreed for the concerned examination in these rules or in the Rules and Regulations.

2. The examination is completed successfully if the result has been qualified as at least a ‘pass’.

시험 결과의 고지 및 성적부여 Article 2.10 – Grading and publication of examination results

일반적으로 20일 이내, 구술시험은 즉시 또는 여러 학생이 연속해서 볼 경우 5일 이내

1. Unless other rules have been specified in these rules or the Rules and Regulations, the examiner will grade an examination or a part of an examination within 20 weekdays (weekdays being Mo-Fr) of the day the examination was taken. The examiner provides the organisation of education/the secretariat of the Examination Board of Medicine with the relevant information in behalf of the publication of the examination results to the student. The publication of the examination results to the students will also take place within 20 weekdays (weekdays being Mo-Fr) of the day the examination or a part of the examination was taken.

2. In contravention to section 1, the examiner will grade an oral examination (or part thereof) immediately after taking said examination and provide the concerned student and the organisation of education/ the secretariat of the Examination Board of Medicine with evidence of the grade. If multiple students take the same examination soon after one another, this term of notification may be extended by 5 weekdays.

성적 검토 권한 Article 2.11 - Right of inspection

1. Within 10 weekdays (weekdays being Mo-Fr) (at most) of the announcement of the results of a written (including computer-based) exam, the student will have the right to request inspection of the assessed work.

2. Within the period mentioned in paragraph 1, the student will have the right to request inspection of the exam questions and assignments, and the standards used to assess them.

3. The announcement of a written (including computer-based) exam’s results will specify how the right of inspection can be obtained.

시험과 구성요소의 유효기간 Article 2.12 – Validity of the examinations and components of examinations

통과한 시험의 유효기간은 60개월

1. The period of validity for passed examinations is 60 months.

2. Passed examination components of a not yet passed examination remain also valid for 60 months unless determined otherwise in the relevant rules, including the examination regulations (toetsplannen).

3. The Examination Board of Medicine can extend in exceptional cases the period of validity of passed examinations or components of examinations by a period to be decided by the Examination Board of Medicine itself. The Examination Board of Medicine may impose additional or alternative requirements on the student in the process.

시험의 면제 Article 2.13 – Exemption from examinations

1. The Examination Board of Medicine can at the request of the student grant exemption from certain examinations or parts thereof, if the student can prove that he or she has passed a module comparable in scope and content in another study programme, or if the student can demonstrate to the satisfaction of the Examination Board of Medicine that he/she has acquired competences elsewhere that are comparable to the module for which exemption is being required.

2. Granting exemption does not create any obligation on the part of the Faculty to offer an alternative study programme module.

사기(기만)행위로 인한 처벌기간동안 치른 시험은 고려대상 아님

3. The Examination Board of Medicine will not grant any exemption based on exams passed by a student outside the programme during the period in which the student was barred from taking exams for the programme by the Examination Board of Medicine because of fraud.

재시험 Article 2.14 – Resits

For each failed exam a resit exam will be offered once within the academic year. If you failed an exam that consists of multiple components, you can only resit the components you have failed. Regarding the Professional Behaviour examination year 3, the EC will provide an appropriate resit arrangement/opportunity.

PARAGRAPH 3 – COURSE YEAR 1 ITM

1학년 Article 3 – Study programme and examination programme of course year 1 ITM

1. Course year 1 of the ITM contains the following examination components:

a. Block 1.1 Growth and Development I (7 credits);

b. Block 1.2 Breathing and Circulation I (7 credits);

c. Block 1.3 Regulation and Integration (4 credits);

d. Block 1.4 Thinking and Doing I (7 credits);

e. Block 1.5 Digestion and Defence I (7 credits);

f. Block 1.6 Diabetes, Obesity and Lifestyle (4 credits);

g. Skills examination  year 1 (6 credits);

h. Progress test (5 credits) and the following examinations and assignments:

i. Professional behaviour examination year 1 (4 credits);

j. Portfolio examination year 1 (5 credits).

k. Non-block related assignment: Imaging techniques (1 credit)

l. Non-block related assignment: Personal Formulary (1 credit)

m. Consulting skills and Reflection Education (CORE) year 1 (2 credit)

2. An outline of the content and aims of the examination components listed in section 1 can be found via EleUM.

PARAGRAPH 4 – COURSE YEAR 2 ITM

진입 Article 4.1 - Admission

1. The student is awarded unconditional admission to the study programme and examination programme of course year 2 if the 60 credits of course year 1 have been obtained.

2. The Examination Board of Medicine can conditionally admit the student to the study programme and examination programme of course year 2 before said student has obtained the necessary 60 credits of the first year, on the condition that at least 40 credits have been obtained, of which at least the 25 credits from the block examinations of course year 1, unless the Examination Board of Medicine decides otherwise.

3. The Examination Board of Medicine determines the period of conditional admission. This period is maximum 12 months after the conditional commencement of the study and examination programme of course year 2.

4. Admission to the study programme and examination programme of course year 2 becomes unconditional if at the latest within the period as determined by the Examination Board of Medicine (see section 3 above) the requirements for gaining the 60 credits of course year 1 have been met.
5. The credits obtained from the examinations of course year 2, that the student takes during his or her conditional period of admission, are awarded unconditionally.

2학년 과목 Article 4.2 –  Study programme and examination programme course year 2 ITM

a. Block 2.1  Breathing and circulation II  (7 credits);

b. Block 2.2 Growth and development II  (7 credits);

c. Block 2.3  Elective (4 credits)

d. Block 2.4 Digestion and defense II  (7 credits);

e. Block 2.5 Thinking and doing II (7 credits);

f. Block 2.6 Elective (4 credits)

g. OSCE tests year 2 (6 credits);

and the following examinations and assignments:

h. Progress test (5 credits)

i. Professional behaviour examination year 2 (4 credits);

j. Portfolio examination year 2 (5 credits).

k. Non-block related assignment: Personal Formulary (1 credit)

l. Consulting skills and Reflection Education (CORE) year 2 (3 credits)

2. An outline of the content and aims of the examination components  listed in section 1 can be found via eleUM.

PARAGRAPH 5 – COURSE YEAR 3 ITM

진입 Article 5.1 – Admission

1. The student is awarded unconditional admission to the study programme and examination programme of course year 3 if the 120 credits of course year 1 and 2 have been obtained.

2. The Examination Board of Medicine can conditionally admit the student to the study programme and examination programme of course year 3 before said student has obtained the necessary 60 credits of the second year, on the condition that at least 100 credits have been obtained  of which 60 credits out of year 1, of which at least the 21 credits from the block examinations of course year 2 unless the Examination Board of Medicine decides otherwise.

3. The Examination Board of Medicine determines the period of conditional admission. This period is maximum 12 months after the conditional commencement of the study and examination programme of course year 3.

4. Admission to the study programme and examination programme of course year 3 becomes unconditional if at the latest within the period as determined by the Examination Board of Medicine (see section 3 above) the requirements for gaining the 60 credits of course year 2 have been met.
5. The credits obtained from the examinations of course year 3, that the student takes during his or her conditional period of admission, are awarded unconditionally.

3학년 과목 Article 5.2 Study programme and examination programme course year 3 ITM

1. Course year 3 has as its theme ‘Chronic disorders’. Course year 3 contains the following examination components:

a. Cluster Abdomen (10 credits)

b. Cluster Circulation and Lungs (10 credits)

c. Cluster Locomotor Apparatus (10 credits)

d. Cluster Psychomedical Problems (10 credits)

e. OSCE tests year 3 (2 credits) and the following examinations:

f. Progress test (4 credits);

g. Professional behaviour examination year 3 (4 credits)

h. Portfolio examination year 3 (4 credits)

i. Non-cluster-related programme: Chronicity (1 credit)

j. Non-cluster related programme: health law and health ethics (1 credit)

k. Consultation skills and Reflection Education (CORE) year 3 (2 credits)
l. Academic skills (2 credits)

2. A broad outline of the aims and content of the examination components as listed in section 1 can be found via eleUM.

PARAGRAPH 6 – RESERVED FOR LATER PROVISIONS

시험 PARAGRAPH 7 – EXAMINATIONS

ITM에서의 시험 Article 7 – Examinations in the ITM

The following examinations referred to in Chapter 7 of the WHW must be taken as part of the ITM:

a. The final bachelor’s examination (Article 7.10 of the WHW);

b. The examination for the flexible bachelor’s degree programme (Article 7.3d of the WHW).

최종 시험 Article 7.1 – Final examination

A student will have passed the final bachelor’s examination if he or she has attained all 180 credits for course years 1, 2 and 3 of the ITM.

유연성 Article 7.2 – Flexible bachelor’s programme and examination for the flexible bachelor’s programme

1. A student who is enrolled for the ITM may, with the Examination Board of Medicine’s permission, design his/her own programme from study units given in English by an institution of academic education, with this programme including an examination.

2. The flexible programme must entail a study workload of 180 credits.

3. The Examination Board of Medicine decides whether to grant permission within four weeks after receiving the student’s proposal.

4. The examination for this flexible bachelor’s programme does not entitle the student to admission to the education and examination programme for the follow-up master’s degree.

학위 Article 7.3 – Degree

1.1 Students passing the bachelor’s examination of the ITM for numerus fixus students are awarded the degree of ‘Bachelor of Science’. The degree also indicates the subject area and professional field to which the degree relates.

1.2 Students passing the examination for the flexible bachelor’s programme are awarded a bachelor’s degree. Pursuant to Article 7.10a of the WHW “of science” is added to the degree granted.

2. As proof that the examination was passed, a testimony (getuigschrift) is issued by the Examination Board. The testimony for the examination passed indicates in any event the following:

a. the name of the programme;

b. the components of the examination;

c. (where appropriate) the right to engage in a profession specified in the testimony;

d. the degree awarded;

e. the date on which the programme was most recently accredited or reviewed.

3. Students entitled to receive a testimony may, stating reasons and in accordance with UM rules, ask the Examination Board to postpone issue of the testimony.

4. The testimony is signed by the chair of the Examination Board of Medicine and the dean.

5. The testimony is issued in public, unless the Examination Board of Medicine decides otherwise in exceptional cases.

6. A list of the examination components and a diploma supplement are issued with the testimony.

7. The Examination Board of Medicine can add the distinction ‘Cum Laude’ in accordance with the provisions in the Rules and Regulations.

PARAGRAPH 8 – PREVIOUS EDUCATION

Article 8.1 – Further previous education requirements (profiles)

1. Students who have a diploma referred to in Article 7.24 or 7.28 of the WHW which does not meet the further previous education requirements (profiles) designated under Article 7.25 of the WHW cannot be admitted to the programme until, in the assessment of the Colloquium Doctum and Special Admissions Board, requirements substantively similar to the further previous education requirements (profiles) have been met.

Article 8.2 – Colloquium Doctum (Entrance examination)

1. The admissions test referred to in Article 7.29 of the WHW is performed by the Colloquium Doctum and Special Admissions Board for Medicine.

2. The admissions test consists of the components English language, physics, chemistry, mathematics and biology.

3. The Colloquium Doctum and Special Admissions Board for Medicine can grant an exemption for components of the test if, in the Board’s judgment, the candidate has demonstrated that he or she meets substantively similar requirements.

4. The rules and procedures regarding the admissions test will be included in regulations to be adopted by the Examination Board of Medicine concerning admission requirements to the Maastricht Medicine programme.

Article 8.3 – Previous education for students with non-Dutch diplomas

1. Subject to the third paragraph of this article, students who have a diploma which, pursuant to Article 7.28(2) of the WHW, has been designated by ministerial regulation as at least equivalent to the diploma for pre-university education are exempted from the previous education requirements.

2. Subject to the third paragraph of this article, students who have a diploma, whether issued in the Netherlands or not, which, in the judgment of the Colloquium Doctum and Special Admissions Board for Medicine, is at least equivalent to the diploma for pre-university education may be exempted by the Executive Board from the previous education requirements.

3. Students who have received an exemption from the previous education requirements pursuant to the first and second paragraph cannot be admitted to the programme until, in the assessment of the Colloquium Doctum and Special Admissions Board for Medicine, requirements substantively similar to the further previous education requirements (profiles) have been met.

4. The rules and procedures regarding the assessment referred to in the third paragraph will be included in regulations to be adopted by the Examination Board of Medicine concerning admission requirements to the Maastricht Medicine programme.

Article 8.4 –Vervallen

PARAGRAPH 9 –SERIOUS PROBLEMS REGARDING PROFESSIONAL BEHAVIOUR AND UNSUITABILITY (IUDICIUM ABEUNDI)

부적절한(unprofessional) 행동 Article 9.1 – Professional behaviour and performance in the programme including patient care

1. If at any moment during the programme the professional behaviour of the student is judged, by a tutor, a staff member or a person not directly involved in the programme (in teaching), to be below standard for performing in the programme including patient care, the tutor, the staff member or the person not directly involved in the programme will report this in writing and with reasons stated to the (review) committee of professional behaviour (this applies to all three course years of the ITM). 

2. On the basis of the report, the Examination Board of Medicine, if necessary in consultation with the (review) committee of professional behaviour, will instigate an investigation into the professional behaviour of the student. The Examination Board of Medicine will send written notice of the instigation of the investigation on the basis of this article to the student and to the FHML Board. The investigation will be completed within a period of six weeks.

3. During the investigation, the student and the involved tutor, staff member or person not directly involved in the programme will be heard. The findings of the investigation will be recorded in written form.

4. The results of the investigation will be attached to the notice and included in the study portfolio.

5.The Board of Examiners will seek an individual solution.

등록 취소 Article 9.2 - Unsuitability (Iudicium Abeundi)

1. In exceptional circumstances and after carefully weighing the interests at stake, the Examination Board may, stating reasons, ask the Dean to request that the Executive Board terminate or deny a student’s registration if, through his/her conduct or statements, the student shows that he/she is unsuitable to practice one or more professions for which the ITM is training him/her or is unsuitable for the practical preparation for the profession.

2. If the Dean of the faculty is asked by the Executive Board for a recommendation on a proposed termination or denial of registration based on the reasons stated in paragraph 1, the Dean will in turn ask for a recommendation from the Examination Board. The recommendation to the Dean will be supported by reasons.

PARAGRAPH 10 – LEGAL PROTECTION

항고 권리 Article 10.1 - Right of appeal

When a decision by the examiner and the Examination Board is announced to a student, the student will also be notified of the right to file an appeal with the Office for Student Legal Protection within six weeks after the decision is announced.

PARAGRAPH 11 – FINAL PROVISIONS

Article 11.1 - Amendments

1. Amendments of these rules are determined by the FHML Faculty Board.

2. No amendments will be made that apply to the current academic year, unless it is reasonable to assume that no student interests will be prejudiced.

Article11.2 – Publication

1. The FHML Faculty Board shall ensure suitable publication of these rules, of the Rules and Regulations, and of any amendments to these papers.

2. Any interested party can obtain a copy of the papers as referred to in section 1 from the secretarial office of the FHML Institute for Education.

Article 11.3 – Unforeseen circumstances

In circumstances not provided for by these rules, the Examination Board of Medicine will make a decision on behalf of the Faculty Board. This decision will be in writing and supported by arguments.

Article 11.4 – Hardship clause

The Examination Board of Medicine is authorised to deviate from these rules in individual cases, if the unaltered application will in their opinion, due to exceptional circumstances, lead to serious injustices.

Article 11.5 – Official title

These rules will be referred to as the Education and Examination Rules, International Track in Medicine (ITM) for numerus fixus students, curriculum 2011, academic year 2013-2014.

Article 11.6 – Date of commencement

These rules take effect on 1 September 2013and apply to the academic year 2013-2014.

As established by the dean of the FHML on behalf of the Board of the UMC⁺   on 14 May 2013.

(출처 : https://www.google.co.kr/url?sa=t&rct=j&q=&esrc=s&source=web&cd=2&ved=0CEAQFjAB&url=http%3A%2F%2Fwww.maastrichtuniversity.nl%2Fweb%2Ffile%3Fuuid%3D47550d1f-5317-452e-a9fd-dd05a2891c77%26owner%3D10767728-c015-44db-968c-eb022e3b3932&ei=6-Q0U5b_EMfdigfiyoC4BQ&usg=AFQjCNEI-qNRNc31cfb1YXSMfGe3PIGhMw&sig2=8QT3Hk3-0QPPuNYH6v3W7A)

Students’ perceptions of early patient encounters in a PBL curriculum: A first evaluation of the Maastricht experience

AGNES D. DIEMERS1, DIANA H. J. M. DOLMANS1, MARIJKE VAN SANTEN2, SCHELTUS J. VAN LUIJK3, AMEIKE M. B. JANSSEN-NOORDMAN1 & ALBERT J. J. A. SCHERPBIER1

1Maastricht University, 2University Hospital Maastricht, 3VUmc, Amsterdam, at the time of the study Maastricht University, The Netherlands

Introduction: Real patient encounters before the clinical phase of undergraduate medical education are recommended to stimulate integration of theory and practice. Such encounters are not easy to integrate into the three phases of the problem-based learning cycle, i.e. preparation, self-study and reporting. The authors studied students’ perceptions of problem-based learning with real patient encounters as the starting point for learning.

Method: Students’ perceptions of the programme with real patients were evaluated by means of a questionnaire. Mean item scores on a five-point Likert scale and 95% confidence intervals were calculated.

Results: Students showed satisfaction with the patient encounters and said they learned a lot from them. Reporting was also highly rated, particularly the integration of theory and practice. Preparation and self-study received lower scores.

Discussion: The findings support the view that real patient encounters can act as a powerful driving force for learning and enhance integration of theory and practice. Student learning might benefit from: better information to students and teachers regarding educational objectives, teacher training and careful selection of patients. In order to gain more insight into learning from patient encounters, further studies should address students’ and teachers’ views and behaviours in respect of this type of learning.

Introduction

PBL의 취지와 예상되는 이점에도 불구하고, 학생들은 이론적 지식을 실제 환자에 연결시키기 어려워하고 있으며, 실제 환자를 임상실습교육기간보다 이전에 만나는 것이 이 문제의 해결법으로 제시되었다.

Problem-based learning (PBL) is increasingly being used as an educational approach in medical education. It is supposed to ‘promote the transfer of concepts to new problems and the integration of basic science concepts into clinical problems’ (Norman & Schmidt 1992). Despite this assumed benefit, students in a PBL curriculum have reported difficulty in applying theoretical knowledge to real patient problems when making the transition from preclinical, mainly theoretical courses to clinical training during the clerkships (Prince et al. 2000; 2005). Contacts with real patients during the preclinical phase have been proposed as a solution to this problem (Prince et al. 2000; 2005).

문헌을 통해서도 조기 환자접촉의 효과가 확인되고 있다. 실제 환자의 맥락 속에서 이론을 배울때 'more relevant'해지고 'easier to learn'해진다. 또한 학습의 강력한 원동력이다.

Reports in the literature concerning the use of early patient encounters in PBL have confirmed the beneficial effects of such encounters (O’Neill et al. 2000; 2002; Dammers 2001). New knowledge is better internalized when students can relate it to a real patient (Prince et al. 2000). When students learn theory within the context of real patients, it becomes ‘more relevant’, and is ‘easier to learn’ and easier to remember (Norman & Schmidt 1992; Dornan & Bundy 2004; Littlewood et al. 2005). Furthermore, when real patients are used as the starting point for learning, they act as a powerful driving force for meaningful and profound learning (Norman & Schmidt 1992; Prince et al. 2000; Parsell & Bligh 2001; Dornan & Bundy 2004; Littlewood et al. 2005).

그러나 실제로 환자 접촉을 의학 교육과정에 넣는 것은 가볍게 될 일도 아니고, 그 성공이 담보되는 것도 아니다. 주요하게 거론되는 문제로는 환자의 문제를 교육과정의 주제와 맞추기도 어렵고, 핵심 교육과정을 포괄할만큼 충분한 사례를 확보하는 것도 어렵다.

The actual implementation and integration of patient contacts in medical curricula is an undertaking that should not be embarked upon lightly and success is not to be taken for granted. The main problems reported in the literature are matching patient problems to course themes and expected difficulties in selecting sufficient numbers of suitable cases to ensure coverage of the core curriculum (Bokhoven et al. 1998; O’Neill et al. 2000; 2002; Mainhard et al. 2004). 

또 다른 문제는 학생들이 이론과 실제의 의미있는 연결고리를 찾기를 어려워한다는 것이다. 실제 환자를 만나게 하는 것이 자동적으로 학생들로하여금 환자가 가진 문제의 기전(병태생리)를 학습하게 하지는 않았다. 이 연구에서 학생들은 환자와 학습을 적절하게 연결시키지 못했다고 말했으며, 그 연결이 어떤 것인지가 '제시될' 필요가 있다고 했다. 또한 Eva는 학생들이 자동적으로 analytic reasoning을 사용하지 않으며, 환자의 문제가 어떻게 기초과학과 연결되는지 분명한 교육을 받을 필요가 있고, 여러 문제간 비교를 해줄 필요가 있다고 주장했다.

Another potential problem is students having difficulty identifying meaningful links between theory and practice. One study reported that confrontation with real patients in the curriculum did not automatically result in medical students studying the pathophysiology underlying patients’ problems (van der Wiel et al. 1999). In that study, students said that they did not make the connection between patients and learning of their own accord and that they needed ‘to be shown those links’ (van der Wiel et al. 1999). Additionally, Eva (2004) argues that students do not spontaneously use analytic reasoning, but should be explicitly instructed to link the problems presented by the patient to basic science and make comparisons across problems.

조기 환자접촉과 PBL이 가진 교육적 잠재력을 합해내려면 환자 접촉을 PBL사이클에 적절하게 포함시킬수 있는 방법이 필요하다. PBL 사이클을 세 단계로 이뤄진다. 준비-자습-보고. 우리는 준비 단계 이후에 환자를 접촉하는 과정에 대한 연구를 했고, 연구의 목적은 이 4단계 PBL사이클에 대한 학생들의 평가는 어떠한지 보고자 하는 것이다.

In order to realize the combined educational potential of early patient encounters and PBL, a way has to be found to effectively integrate real patient encounters into the PBL cycle. The PBL cycle generally comprises three phases: preparation, self-study and reporting. We studied a course in which real patient encounters were incorporated into the PBL cycle immediately after the preparation phase (Figure 1). The aim of our study was to evaluate students’ perceptions of their learning organized around this four-phase PBL cycle, in which a real patient encounter was introduced as a driving force for student learning.

교육적 배경 Educational background

2001년 Maastricht 의과대학의 6년제 PBL교육과정에 전방위적 개혁이 이뤄졌다. '낡은'교육과정은 명확히 구분되는 두 개 시기로 나눠져있었다 (4년 전임상실습, 2년 임상실습). 새로운 교육과정의 목적은 학생들이 실제 환자와의 경험을 조기에 할 수 있도록 하는 것이다.

In 2001, extensive innovations were introduced into the six-year PBL curriculum of Maastricht Medical School, the Netherlands. The ‘old’ curriculum consisted of two distinct phases: a four-year preclinical phase in which PBL tutorials were the predominant educational method and two years of mainly hospital-based clinical clerkships. One of the aims of the new curriculum is to offer students experiences with real patients earlier in the curriculum. 

이를 위해 3학년에서 실제 환자와의 잦은 접촉 기회를 포함시켰고, 새로운 3학년 교육과정의 주제는 '만성질환' 이었다. 이 주제는 크게 네 개의 클러스터로 나눠진다. 매주 학생들은 외래 클리닉에서 환자를 본다. 환자와의 접촉은 PBL사이클의 시작점이고, 각 사이클은 일주일간 진행되며 10명의 학생과 학생들의 코치가 함께하는 4시간짜리 tutorial, 모든 학생들의 환자 접촉, 환자 접촉과 다음 tutorial 사이의 자습시간으로 구성된다. 

In Year 3 this is realized by the introduction of frequent real patient encounters. The theme of the new Year 3 is Chronic Diseases. This theme is divided into four subject clusters, i.e. abdominal region, locomotor system, circulation & lungs and psychomedical problems & mental healthcare. Every week students see a patient in the teaching outpatient clinic at University Hospital Maastricht. The patient encounters are the starting point for learning in the PBL cycle. Each cycle lasts a week and comprises one four-hour tutorial attended by 10 students and their coach, patient encounters for all students, and self-study between the patient encounter and the next tutorial. 

우리는 PBL의 첫 phase를 둘로 나누었다. 하나는 준비시기로, 학생들이 환자 대면을 준비하고 사전 지식을 모으는 단계이다. 환자 대면 시기는 학생들이 짝을 이뤄서 실제 환자를 만나는 것이다. 이 환자 대면으로부터 학생들은 자습할 학습 주제를 찾는다. 

We divided the original first phase of PBL tutorials into two phases: the ‘preparation phase’ in which students prepare for the patient encounter and activate prior knowledge and the ‘patient encounter phase’ in which students, in pairs, meet a real patient instead of a paper patient. From this encounter students derive learning issues for self-study. 

그 결과 네 개의 연속된 시기가 PBL사이클을 구성한다.

As a result, four consecutive phases can be discerned in the PBL cycle. 

The preparation phase takes up the last hour of the tutorial, 

the patient encounter phase is scheduled one or two days after the tutorial, (튜터리얼 1~2일 후)

the self-study phase covers the time between the patient encounter and the tutorial in the next week, and 

the reporting phase takes place during the first three hours of the tutorial. 

PBL사이클은 3학년의 주요한 교육요소이며, 강의자, 술기훈련, 그 외 다른 교육활동으로 보충된다. 이 네 phase의 내용은 아래에서 더 자세히 다룬다.

The PBL cycle is the main educational component of Year 3 and is complemented by lectures, skills training and other educational activities. The content of the four phases will now be discussed in some detail.

1. Preparation phase

The students are given the GP’s letter of referral or a vignette (Box 1) describing the problem (or a similar problem) of the patient they will see in the outpatient clinic. The patient problems are elaborated on by the group in order to activate the knowledge gained during the preceding two years of the curriculum. During elaboration, attention is also being paid to history-taking and physical examination. The students then generate learning issues and decide what to study in preparation for the patient encounter.

2. Patient encounter phase

One or two days after the preparation phase, student pairs go to the outpatient clinic where they take a history and perform a physical examination of a patient. After about 30 minutes, when history and physical examination are finished, the students consult the patient’s attending physician, who acts as their ‘clinical supervisor’. The students and the clinical supervisor then return to the patient to complete the consultation. The role of the clinical supervisor is to guide the students in generating learning issues on the basis of the problem presented by the patient and to give the students feedback on their performance.

3. Self-study phase

During the self-study phase the students work on the learning issues derived from the patient encounter. They make use of a variety of learning resources, such as books, skills training, lectures and so on. The student pairs prepare a clinical presentation on ‘their patient’ to present to the group during the reporting phase.

4. Reporting phase

This phase is partly devoted to the patient presentations, which consist of a report on history, physical examination, differential diagnosis and management plan. The presentation is followed by a discussion of what the students have learned during the patient encounters and self-study phase. The purpose of this phase is to promote integration of theory and practice. Students apply their newly acquired knowledge to the patient problems.

The coach and the clinical supervisor are both clinical staff members of the disciplines involved in the Year 3 programme. Both have had two hours’ training in advance in which it is explained to them how to guide the session as a coach and clinical supervisor.

Instruments

For this study we analysed the results of the anonymous questionnaire of the regular curriculum evaluation, which is administered routinely to all students at the end of each cluster (Appendix 1). This means that each student could complete four questionnaires over the course of the year. The questionnaire is identical for the four clusters and consists of 10 statements with a five-point Likert scale (1=fully disagree, 5=fully agree): two statements about the preparation phase, three about the patient encounter phase, two about the self-study phase and three about the reporting phase. An example of a statement about the preparation phase is: ‘The tutorials provided sufficient preparation for the patient encounters.’ An example of a statement about the patient encounter phase is: ‘I learned much from the patient encounters.’

Analysis

Data were analysed using the Statistical Package for Social Sciences (SPSS version 12.0.1). Mean item scores across all students were calculated for each cluster separately. In this way 10 scores were obtained for each of the four subject clusters. Mean scores below 3.0 were considered unsatisfactory and indicative of a strong need for improvement. Mean scores of 3.0–3.4 were considered borderline, i.e. necessitating some improvement and mean scores of 3.5 or higher were considered good. We determined 95% confidence intervals (95% CI) for the mean item scores to determine whether a score differed significantly (p < 0.05) from 3.5.

Conclusions and discussion

Overall, students appear to be satisfied with the patient encounter phase and indicate that they learn a great deal from it. This supports Dornan’s (Dornan & Bundy 2004) findings that early patient contacts have the potential to enhance learning. The reporting phase is also rated highly. Students strongly agree that the patient encounters are discussed adequately during this phase. This positive view is reinforced by the relatively high scores concerning connecting theory and practice. These results are indicative of positive effects of the early introduction of real patient encounters in a PBL curriculum (Dornan & Bundy 2004). This can be seen as support for the view that real patient encounters can act as a powerful driving force for meaningful and profound learning (Norman & Schmidt 1992; Prince et al. 2000; Dornan & Bundy 2004; Littlewood et al. 2005). It should be taken into account, though, that further research is needed to further investigate the value-added of real patients in PBL.

Students' perceptions of early patient encounters in a PBL curriculum: a first evaluation of the Maastrichtexperience.

The findings support the view that real patient encounters can act as a powerful driving force for learning and enhance integration of theory and practice. Student learning might benefit from: better information to students and teachers regarding educational objectives, teacher training and careful selection of patients. In order to gain more insight into learning from patient encounters, further studies should address students' and teachers' views and behaviours in respect of this type of learning.

FACULTY OF MEDICINE INSTITUTE OF MEDICAL EDUCATION CLINICAL EDUCATION DIRECTORATE MAASTRICHT 2003

THE NEW MAASTRICHT CURRICULUM YEAR3 : CHRONIC DISORDERS

Composed by M. van Santen and S.J. van Luijk, in cooperation with the cluster coordinators: H. Crijns, T. Delhaas, E. Heineman, R. Geesink and T. Schmidt; 

the coordinators of non-cluster-related education: R. Ottenheijm, J. van Eijk, J. Schouten, R. Houtepen, J.-J. Rethans, J. van Dalen; C. van der Vleuten and other members of the Department of Educational Development and Research

법과 윤리 

HEALTH LAW AND ETHICS

여기서는 윤리적/법적 문제들을 다루고 있다. 핵심 주제는 의사-환자 관계이며 네 개의 세부 주제로 나누어진다.

the professional, 

informed consent and autonomy, 

privacy,

representation of relatives. 

This part of the programme is based on ethical and legal issues the students meet in their contacts during the outpatient encounters and in practice. The central theme is the doctor-patient relationship, subdivided into four smaller themes: the professional, informed consent and autonomy, privacy and representation of relatives. 

학생들은 클러스터와 관련된 학습자료/과제를 받고 짝을 이루어 과제를 해야 한다. 주제는 다음과 같다.

The students are given cluster-related study materials and assignments they have to work on in pairs. 

The subjects are: 

Errors and mistakes, Conflicting insights (Circulation and lungs cluster); 

Protocols/Privacy/Professional secrecy (Locomotor apparatus cluster); 

Age and lifestyle, Compliance (Abdomen cluster); 

Informed consent (care giver) and Informed consent (patient) (Psychomedical cluster). 

과제에 대한 정보는 OPE동안 축적되며, 학생들은 짧은 보고서를 쓰고 그것을 base group 미팅에서 발표한다. 이 교육과정은 다음을 포함한다.

Information for the assignments is compiled during the outpatient encounters. The students write a short report and present it in their base group meeting. This part of the educational programme includes:

An introductory lecture at the beginning of the year, in which the organisation of the year programme is explained

Selection and electronic presentations of thematic case studies by students (in pairs)

Discussion about thematic cases led by a health law and ethics teacher

Year assignment resulting in a paper focussing on the application of information from ethical and legal literature into practical situations

Tutorial lecture to support students in their year assignments.

강의 LECTURES

강의는 interactive하며, 최대 1주에 4시간까지 있다.

The lectures are interactive and take up a maximum of four hours per week.

실습

PRACTICALS

임상표현에서 다뤄지는 주제들은 다음에 대한 실습을 포함한다.

The subjects addressed in the clinical presentations are supported by practicals about:

Anatomy

Imaging techniques

Physiology

Medical informatics and statistics

Medical microbiology.

술기 훈련

SKILLS TRAINING

OPE와 다른 field contact에서의 학습효과를 최대화하기 위해서 학생들은 술기훈련프로그램을 받아야 한다. Abd/Loco/Circ 클러스터의 첫 주에 술기 훈련이 시작된다. 

In order to maximize the learning effect of outpatient encounters and other field contacts, the students follow a skills training programme at the Skillslab. In the first weeks of the clusters Abdomen, Locomotor apparatus and Circulation and lungs, the skills training starts with super- vised patient encounters. 

Base group에서 학생들은 병력 청취와 신체 검진을 연습한다. 그 후 학습목표를 설정하고, 감독하 환자 접촉(supervised patient encounter)은 학생들이 독립적으로 field contact를 하기 위한 준비과정이다. Skillslab 훈련 외에도 수기훈련세션에 대한 통합적 리뷰세션이 해부학 재교육 세션에서 제공된다. 

In their base groups, the students practise history taking and physical examination in a patient with a chronic disorder, supervised by a Skillslab trainer or sometimes their base group coach. Subsequently, they formulate learning goals. These supervised patient encounters are meant to prepare the students for their independent field contacts. Besides the usual Skillslab training, integrated review skills training sessions that are organized simultaneously with anatomy refresher sessions. 

세션에서 학생들은 해부학지식을 refresh할 뿐만 아니라 신체검진기술을 익히게 된다.이 트레이닝 세션은 최대한 사례 학습을 중심으로 한다.

In one session the students can refresh their knowledge of anatomy as well as repeat physical diagnostic skills with the help of the Skillslab trainers and anatomy teachers present. The training sessions are as much as possible based on case studies.

평가

ASSESSMENT

도입

INTRODUCTION

시작점은 Blueprint 2001에 기술된 성취레벨이다. 즉, 평가가 교육의 한 부분이며, 학습과 학습에 대한 학생 스스로의 책임을 촉진해야 한다는 개념이다. 역량에 대한 평가는 밀러의 피라미드에 기반한다. 학생은 교육 프로그램의 요구조건이 달성되었다는 것을 보여줄 수 있는 포트폴리오를 작성하고, 멘토와 함께 토론한다. 클러스터 관련 평가와 클러스터 비관련 평가를 구분한다.

The starting points are the achievement levels stated in ‘Blueprint 2001: training of medical doctors in the Netherlands’, the concept that assessment is an integrated part of education and should stimulate learning, and the student’s own responsibility. Competence is assessed on the basis of the levels of Miller’s pyramid: knows (theoretical knowledge), knows how (knows how knowledge and skills should be applied) shows how (applies knowledge and skills in test situation), does (applies knowledge and skills in practice).5 The student composes a portfolio which proves that the requirements of the educational programme have been met and discusses it with the mentor. A distinction is made between cluster-related en non-cluster-related assessment.

클러스터 관련 평가

CLUSTER-RELATED ASSESSMENT

클러스터 관련 평가는 학생이 스스로의 발전과 수행능력에 대해 모은 포트폴리오를 바탕으로 한다. 이는 의사의 네 가지 역할에 대한 것과 관련이 있다. 의료전문가/과학자/보건의료인/사람. 

Cluster-related assessment is based on the cluster portfolios in which the students compile information about their progress and performance in the four roles of a medical doctor: medical expert, scientist, health care worker and person. 

학생이 모으는 정보는 예를 들면, 시험결과라든가, 윤리나 법과 관련된 보고서, 과제, 코치나 감독의 관찰결과, 환자 접촉을 바탕으로 한 보고서, psychomedical 클러스터 발표, 학생의 역할에 대한 평가, CAT 등이 있다. 이 자료들을 모으는 것은 학생 스스로의 책임이다.

The information consists of, for instance, results of written tests, a paper on ethics and health law, assignments, observations of the coach and supervisor of the practicals, reports based on patient encounters, psychomedical cluster presentation, evaluation of the student’s functioning and a CAT. It is the student’s own responsibility to compile this information in their portfolios.

코치는 클러스터 포트폴리오를 평가한다. 최종 평가와 별도로, 학생들은 네 가지 역할에 대한 피드백을 받게 된다. 평가를 담당한 teaching staff는 어떻게 피드백을 줘야 하며 포트폴리오를 기반으로 어떻게 평가를 해야 하는가에 대한 훈련을 받는다.

The coach assesses the cluster portfolios. Besides the final assessment of each cluster, the students receive feedback on their four different roles as a future doctor twice in each cluster. The teaching staff with assessment roles will be trained, particularly on how to provide feedback and assess students on the basis of a cluster portfolio.

클러스터 비관련 평가

NON-CLUSTER-RELATED ASSESSMENT

클러스터 비관련 평가는 전통적인 평가법(진단평가, 스테이션 평가)을 이용한다. 전문직으로서의 행동에 대한 평가 역시 여기에 포함된다. Station test는 술기와 지식을 모두 포함한다. 

Non-cluster-related assessment consists of traditional tests such as progress tests and a station tests. Assessment of professional behaviour is also part of the non-cluster-related assessment. Station tests cover both skills and knowledge. 

새로은 시험 포멧도 있다.

New test formats are: 

year assignment based on field contacts in general practices, 

health law and ethics and 

the year patient programme. 

또한 학생들은 일년간의 포트폴리오를 제출하는데, 클러스터 포트폴리오에서 일부 선택해서 포함시키는 것도 있으며, 의사의 역할에 대해서 약점/강점을 분석한 것, 학생에 대한 평가 등이 포함된다. 멘토와 학생은 최소 일년에 2회 이상 토론을 한다. 이 미팅의 주된 초점은 약점/강점을 분석해서 학생과 관련된 약속을 하는 것이다.

Also, the student has to submit a year portfolio. It includes a selection of information from the cluster portfolio, weakness/strength analyses per role of the medical doctor and the agreements made with the student. The portfolio is discussed at least twice a year by the mentor and the student. The main points of these meetings are to discuss the weakness/strength analyses per role and the appointments about it with the students.

교수

TEACHING STAFF

다음은 3학년에 teaching staff이 해야 하는 역할이다. 각각의 역할에 대해서 해당 기간과 전문영역, 주요 업무가 기술되어 있다. 클러스터 관련 교수역할은 매 10주마다 수행되어야 한다. 그러나 매 시기에 반드시 동일한 사람이 해야 하는 것은 아니다.

The following list outlines the teaching roles in year 3 in which the teaching staff is directly involved in the implementation of education and training. For each role, the period of the academic year it needs to be fulfilled, the required expertise and main tasks are indicated. Cluster-related teaching roles are to be fulfilled in every period of ten weeks. However, these roles do not have to be taken up by the same person in every cluster period.

ROLES OF TEACHING STAFF IN YEAR 3

Mentor

In years 3, 4 and 5 guidance of individual students; discussion and assessment portfolio.

Year coach

Coaching of a group of 10 students for YPP/SPE/Intervision throughout the year; general practitioner; specialized in cluster-related and non-cluster-related aspects of chronic disease.

Cluster coach

Coaching of a base group of 10 students during a cluster period; specialized in chronic disease; role in cluster-related assessment.

Clinical supervisor

Supervision in several clusters of the field contacts in mental health care, nursing homes and rehabilitation centres; specialized in chronic disease.

- Supervision during the entire year of the same students in a general practice; general practitioner; particularly specialized in generic aspects of chronic disease

- Supervision during student-centred outpatient encounters (OPE) at a student-centred azM outpatient clinic; specialized in chronic disease; provides feedback on activities and performance of the students during the OPEs.

Lecturer

Occasional; lectures are repeated in each of the four cluster periods; specialized in chronic disease.

Supervisor of the practicals

Depends on practical.

Skills trainer

Spread over the year; Skillslab trainer.

학생

STUDENTS

한 학생의 한 주 스케줄은 다음과 같으나 단지 사례일 뿐이다. 실제 스케줄은 클러스터 내에서, 클러스터간 다를 수 있다. 일부 OPE나 YPP등은 특정 시간에만 하는 것은 아니다. 예를 들어서 한 주는 base group meeting이 있었던 금요일 마지막 시간에 시작될 수도 있다.

To give an idea of how the activities will be spread over a week, a possible week schedule of a third-year student is described below. Please note that it is only an example! The real schedules may vary within a cluster and between clusters. Some educational activities (OPEs, base group meetings, YPP) do not take place on fixed days or times. A week may start, for instance, in the last hour of a base group meeting on Friday in which the outpatient encounter or other field of the coming week is prepared.

아래 그림은 교육 사이클에 대한 것이다. 이 사이클의 핵심은 base group meeting에서 OPE를 준비하는 것, 환자 접촉, 자습, 피드백과 토론이다.

This figure represents the educational cycle. The central part of the cycle includes preparation of the outpatient encounters (OPE) in the base group meeting, patient encounters, self-study and feedback/discussion in the base group. 

임상표현과 만성질환의 특정 클러스터 관련 측면에 초점을 두며, psychomedical cluster에서 OPE는 정신건강병원에서 하는 것으로 대체된다. YPP, CATs, 법과 윤리 등과 같은 다른 3학년 프로그램들이 OPE 사이클과 base group meeting을 지원하는 구조이다.

The emphasis is on the clinical presentation and cluster- related aspects of chronicity. In the psychomedical cluster, the OPEs at the student-centred outpatient clinic are replaced by field contacts in mental health care institutions. The cycle of OPEs and base group meetings is supported by the other activities in year 3: year patient programme (YPP), CATs, health law and ethics.

아래는 teaching staff와 학생이 만난느 것을 그린 것이다.

The figure below shows the student’s contacts with teaching staff.

FINALLY

3학년은 새 교육과정 중에서 교육과정이 가장 급격하게 변하는 학년이다. 이 프로그램은 학생과 교수 모두에게 큰 도전이다. 개발그룹은 실천 속에서 배우는 것(learning in practice)을 주요 원칙으로 삼았다. teaching staff는 임상실습 감독관으로서 학생이 경험을 기반으로 학습하는 것을 도울 수 있다. 또는 학생이 더 깊은 지식을 탐구하고 실제 진료에 대한 통찰을 얻으며, 어떻게 환자를 큰 맥락속에서 볼 수 있는가를 도와주는 코치일 수도 있다.

The third year is definitely the year in which changes of the new curriculum are most drastic. The programme contains many challenges for both teaching staff and students. The planning groups have developed a programme in which ‘learning in practice’ is the guiding principle. The teaching staff can be clinical supervisors and contribute to the student’s learning on the basis of their own expertise. Or they can be coaches who help the students to gain in-depth knowledge and insight of real practice and how to see a patient in context. 

교육과 감독과 코칭을 적절히 사용하는 것은 학생의 역할이며, 목표가 달성된다면 2001교육과정의 학생들은 임상실습에서 더 많은 것을 배우고, 더 독립적이 될 것이며, 의학적 의사결정을 비판적으로 내릴 수 있는 능력을 갖출 것이다. 

It is the student’s responsibility to make good use of the education, supervision and coaching that is offered. If the year goals are met, ‘Curriculum 2001’ students will be better able to learn from their clerkships and will be more self-reliant and critical with respect to their medical decisions and abilities. 

교육과정은 항상 계획대로 되지 않는다. 프로그램을 향상시키는 것은 학생과 교수 모두의 몫이다. 클러스터는 3학년동안 네 번 반복되기 때문에 한 해 안에서도 개선이 가능하다. 향후 학생과 교수 모두에게 있어서 새로운 가능성이 기대된다.

An educational programme may not always work according to plan. It is the responsibility of the students and the teaching staff to improve the programme. Since the clusters are repeated four times in year 3, it is possible to make improvements during the year. In conclusion, the third year is a challenging one for those who are organizing it; the logistics of the programme are very complex. It is a year to look forward to, for both students and teaching staff, because it offers many field contacts and new possibilities.

(출처 : http://members.home.nl/h.e.stoffers/UM_med_year3_2001.pdf)

FACULTY OF MEDICINE INSTITUTE OF MEDICAL EDUCATION CLINICAL EDUCATION DIRECTORATE MAASTRICHT 2003

THE NEW MAASTRICHT CURRICULUM YEAR3 : CHRONIC DISORDERS

Composed by M. van Santen and S.J. van Luijk, in cooperation with the cluster coordinators: H. Crijns, T. Delhaas, E. Heineman, R. Geesink and T. Schmidt; 

the coordinators of non-cluster-related education: R. Ottenheijm, J. van Eijk, J. Schouten, R. Houtepen, J.-J. Rethans, J. van Dalen; C. van der Vleuten and other members of the Department of Educational Development and Research

출발점

STARTING POINTS

The educational starting points of the third year are stated in the booklet about the New Maastricht Curriculum.1 The content of the third year is based on ‘Blueprint 2001: training of medical doctors in the Netherlands’.2,3 

요약하자면, 교육과정의 목적은 학생이 장차 의사로서 역할을 하면서, 점차 높아지는 독립성과 책임을 능숙히 다룰 수 있게 하는 것이다.

In summary, the aim of the curriculum is that students can handle increasing independence and responsibility in their role of medical doctor. 

Teaching staff의 역할은 학생이 독립적인 전문직으로 성장하기 위하여 필요한 지식과 술기를 습득하는 과정을 도와주는 코치의 역할이다. 학생들이 이론과 실제를 따로 배우는 것이 아니라 같이 학습하는 것이 중요하다.

The role of the teaching staff is mainly that of a coach who helps the student to acquire the knowledge and skills he or she needs to become a self-reliant professional. In order to learn effectively, it is important that the student does not explore theory and practice separately but in relation to each other. 

평가는 학습의 한 과정으로, 교육과정의 마지막이 아니라 교육의 한 부분이다. 과학적인 훈련과 전문직으로서의 바람직한 행동은 교육과정을 꿰뚫는 중요한 요소이다.

Assessment guides the learning process and is therefore not a final part but an integrated part of education. Scientific training and professional behaviour are the main threads throughout the curriculum.

3학년 교과과정에서는 학생의 책임과 능동적인 자세로 여러 환자를 만날 것을 강조함으로서 이러한 starting point를 반영하고 있다. Teaching Staff는 학생들이 환자와 접촉하게 되는 것을 준비할 수 있게 도와주고, 피드백을 주고, 과제를 평가한다. 이를 위해서 teaching staff는 튜터로서 뿐만 아니라 해당 분야에서 전문가여야 한다. 학생들은 피드백을 통해 필요한 학습목표를 설정하고 이로부터 지식/술기/전문직업성을 학습한다.

In year 3 these starting points are reflected in the emphasis on the student’s responsibility and the large number of patient encounters in which the student takes on an active role. The teaching staff helps the students to prepare for the encounter, provides feedback and assesses assignments. This requires the teaching staff to be experts in their field as well as skilled tutors. The feedback students receive should stimulate them to formulate useful learning goals that enhance their knowledge, skills, and professionalism.

평가의 한 부분으로서 cluster-related portfolio와 year portfolio를 작성하게 함으로서 학생들이 독립적으로 활동할 수 있는능력을 키워주고자 했다. 또한 학생들은 다양한 그룹과 환경에서 협력적으로 학습한다. Critical Appraisal of a Topic (CAT) assignments을 통해서 과학적 접근방법을 배운다. CAT에서 학생들은 임상에서 어떤 선택을 하고 진료를 하는 '근거'를 비판적으로 탐색하게 되며, 이 프로그램은 학생과 teaching staff 모두에게 그 아이디어와 initiative가 열려 있다.

As part of the assessment, the students’ ability to work independently is reflected in the responsibility to build a cluster-related portfolio and a year portfolio. Moreover, the students learn to work together in different groups and circumstances, for example in general practices, outpatient clinics, homes and care centres, or at a patient’s house. A scientific approach is particularly trained in the Critical Appraisal of a Topic (CAT) assignments, in which the students are to search critically for ‘evidence’ as a basis for clinical choices and practice. The programme is open to ideas and initiatives of both the students and the teaching staff.

3학년 : 만성 질환

CONTENT YEAR 3: CHRONIC DISORDERS

각각의 교육과정은 핵심 주제가 있다. 2001 교육과정에서 1학년은 급성질환을, 2학년은 생애 주기를, 3학년은 만성질환을 다루게 된다. 

Each curriculum year has its central theme. Where the first year of the 2001Curriculum focuses on acute disorders and the second year on the stages of life, the third year is centred around chronic disorders. The general starting points are the four areas of a medical doctor’s competence as stated in ‘Blueprint 2001: training of medical doctors in the Netherlands’: the doctor as a medical expert, scientist, health care worker and person.2 

이 프로그램에는 다음의 것들이 포함된다.

The programme includes...

the clinical aspects of chronic disorders, 

the effect on the patient’s life and the people around him, 

and the role of a doctor as care giver. 

만성질환과 모든 측면에 있어서 임상표현이 학생에게 주어지는데, 이들 임상표현은 최대한 실제와 비슷한 것으로 사용한다. 

Clinical presentations are used to confront the students with all aspects of chronic disorders. The presentations are as authentic as possible and deal with the problems patients see their doctor about. This means a lot of learning is based on the context of daily practice in health care. 

3학년은 10주단위로 된 4개 클러스터로 나눠진다. 각각의 클러스터에서는 아래의 것들을 다룬다.

The year is divided into four clusters of 10 weeks, each cluster covering a particular field with various themes and addressing several pathophysiological aspects. In addition, each cluster pays attention to general lines of knowledge, skills and personal aspects as well as disorders that fit into more than one particular cluster. Finally, the clusters include generic aspects with regard to the consequences of chronic disorders that are relevant in the patient encounters in general practice and in the longitudinal patient encounters.

수업 구성

INSTRUCTIONAL FORMATS

도입

INTRODUCTION

3학년의 내용은 네 개의 클러스터로 나눠진다. 한 학년은 네 그룹으로 나눠져서 서로 다른 순서로 네 개 클러스터를 돌게 된다. 

The content of the third year is divided over four clusters of ten weeks, each focussing on a particular subject area. The year group is split into four groups of students who will follow the clusters in a different order. So, each cluster is repeated four times during the year. The subject areas are: 

Abdomen, 

Locomotor apparatus, 

Circulation and lungs, and 

Psychomedical problems and mental health care. 

정규 수업 구성은 다음의 것들이 있다.

Regular instructional formats in year 3 include outpatient encounters (OPE) in a student-centred outpatient clinic at azM/base group meetings, field contacts, year patient programme (YPP)/simulated patients encounters (SPE)/Intervision, Health Law and Ethics, and Critical Appraisal of a Topic (CAT). 

추가로 다음의 것들이 있다.

In addition, lectures, practicals and skills training programmes are offered. The educational formats are discussed below. The diagram outlines the organisation of the educational programme in year 3.

외래환자

OUTPATIENT ENCOUNTERS (OPE)

복부/Locomotor/Circulation에서는 OPE가 있음. 특별히 마련된 학생중심의 외래에서 수행되며, 만성질환의 질환특이적 측면을 보게 됨. 학생은 서로 짝이 되어 한 사람은 의사, 다른 사람은 관찰자 역할을 해서 병력청취와 신체검진을 수행. OPE직후에 의사가 피드백을 제공.

During the clusters dedicated to Abdomen, Locomotor apparatus and Circulation and lungs, 

weekly outpatient encounters (OPE) take place a special student-centred outpatient clinic at azM. 

These encounters focus on the disease-specific aspects of chronic disease. 

In pairs, the students practice on a patient; one student acts as the doctor, the other observes. 

They take the patient’s history and examine the patient. 

Immediately after each OPE, a doctor of the outpatient clinic provides feedback on the students’ performance. 

Base group은 아래와 같다.10명의 학생과 1명의 클러스터 코치. 한 클러스터동안 동일하고, 매주 4시간 모임. 학생들은 한주간의 OPE경험을 바탕으로 발표.

Subsequently, the students have approx. two days for self-study and preparation to report on their OPE in their base group. A base group consists of ten students and a cluster coach. The group remains the same during one cluster and has fourhour meeting every week. 

During these meetings, the students present their findings based on their OPE or field contact in that week. The last hour of the meeting is used to prepare for the OPE of the following week. More detailed information about this educational format can be found in the text boxes below.

Psychomedical 클러스터에서의 field contacts

FIELD CONTACTS IN THE PSYCHOMEDICAL CLUSTER

정신건강병원(mental health care institution) 등에서 field contact가 있음.

There are no outpatient encounters in the psychomedical clusters, instead the students have field contacts in a mental health care institution, nursing home or general practice. The students work along with someone at their field contact address for one day a week. 

처음에는 학생은 관찰만 하지만 점차 참여가 늘어난다. OPE와 마찬가지로 base group meeting에서 발표하고 평가한다. 

First, the student only observes, but gradually his or her active participation increases. Similarly to the outpatient encounters, the field contacts are prepared and evaluated in the base group meetings. The focus is on gaining in-depth knowledge of aetiology, differential diagnosis, course and treatment options.

nursing home이나 general practice의 field contact는 학생들로 하여금 정신건강병원 바깥에서 이뤄지는 것을 가르치려는 목적임. 마지막 주간에 학생들은 plenary presentation을 함.

The field contacts in nursing homes and general practices aim to teach the students to recognize psychomedical problems outside the setting of a mental health care institution. During the last week of the psychomedical cluster, the students give plenary presentations.

모든 클러스터에서의 Field contact

FIELD CONTACTS IN ALL CLUSTERS

일년간 모든 학생은 한 general practice를 10~12회 방문하여 해당 클러스터 주제와 관련된 환자를 만난다. 이러한 general practice에서의 접촉은 직접적으로 질병과 관련되지 않은 만성질환의 일반적 문제를 경험하게 한다.

During the year, every student visits one general practice 10 to 12 times and meets patients with problems that are relevant to the subject area of the present cluster. In addition, these contacts at general practices enable the students to deal with generic aspects of chronic disease that are not directly disease-related. 

매 방문마다 학생은 2~5명의 환자를 보고, GP코치로부터 피드백을 받는다. 이 GP는 학생의 리포트에 대해서도 평가를 하고, 이 리포트는 클러스터 포트폴리오에 포함된다.

For each cluster period, goals and tasks have been formulated with respect to these aspects. During each visit, the student sees two to five patients and receives subsequent feedback from the ‘coaching’ GP. This GP also provides feedback on the student’s reports of his visits to the practice. The reports are included in the cluster portfolio. 

Field contact는 base group meeting에서 준비하고, 이 미팅에서 평가한다. 매 10주마다 만성질환의 특정 한 측면이 주어진다. 전체 1년간 1. Epidemiology and chronic disorders 과  2. Disease management 로 나뉘어서 만성질환의 진행/원인/치료에 대해 초점을 두게 된다. 

Field contacts are prepared and evaluated in the base group meetings. Every ten weeks, special attention is given to one particular generic aspect of chronical disease, both in the field contacts and in the year patient programme. During the entire year, attention is paid to the course, cause and therapy of chronic disorders, divided into 1. Epidemiology and chronic disorders and 2. Disease management (longitudinal aspects, care plans and care chains). These aspects are included in the theoretical part (in base groups) as well as in practice (in tasks with patients).

Locomotor와 Circulation에서는 재활센터에서의 field contact도 있다.

There are also field contacts in a rehabilitation centre during the clusters Locomotor apparatus and Circulation and lungs.

YPP/SPE/인터비젼

YEAR PATIENT PROGRAMME (YPP)/SIMULATED PATIENT ENCOUNTERS (SPE)/INTERVISION

이 부분은 실제 환자/가상 환자 등과 만나고 토론을 하게 된다. 10명의 학생과 일년간 맡아줄 코치가 한 그룹을 이룬다.

These parts of the educational programme include contacts with real patients, simulated patients and discussions in YPP/SPE/Intervision groups. These groups consist of 10 students and a year coach, and remain the same for the entire year. 

각각의 그룹에는 모든 클러스터의 학생들이 모두 속해있기 때문에 각각의 학생들은 서로 다른 경험을 가지고 있다. 코치는 일년간 이 그룹을 담당하기 때문에 학생의 발달을 꾸준히 따라갈 수 있다. 1년간 8회의 YPP 9회의 SPE/인터비전 미팅/1회의 시작미팅/1회의 최종미팅이 있다. 각 미팅은 일년 코치 외에 또 다른 teaching staff이 같이 진행한다.

Each group contains students of every cluster, so the students in each group have different content-related learning experiences. Since the year coach works with the same group of students for an entire year, he or she is well able to follow the student’s development (including professional behaviour) during the year. YPP, SPE and Intervision are explained in more detail below. In total there are 19 meetings: eight YPP-meetings and nine SPE/Intervision-meetings under the supervision of the year coach, and one introductory and one final meeting, that are lead by someone from the teaching staff other than the year coach.

통년 환자 프로그램

YEAR PATIENT PROGRAMME (YPP)

모든 학생은 일년 내내 담당할 환자와 짝을 이룬다. 환자와의 접촉은 'assignment'를 기반으로 이루어지며, 매10주마다 field contact의 주제와 연관된 assignment와 activities가 주어진다.

Every student is paired with a patient that he or she has to follow during the entire year. This enables the student to gain insight into the course of a chronic disorder. The contacts with the patient are based on assignments. Every ten weeks the assignments and activities are tailored to a topic coinciding with the generic themes of the field contacts in the general practices. 

주제는 다음과 같다.

1. Physical, cognitive and emotional restrictions due to chronic disease; 

2. Social participation; 

3. Problem solving ability of patients; 

4. Context of being chronically ill.

The topics are: 1. Physical, cognitive and emotional restrictions due to chronic disease; 2. Social participation; 3. Problemsolving ability of patients; 4. Context of being chronically ill. 

학생들은 정기적으로 설문조사와 health and costs diaries를 활용하여 '만성질환'에 대한 일반적인 측면에 대한 자료를 조사한다. 여기에 포함되는 것은 다음과 같다.

the disablement process, 

self-management, mood problems, 

continuity of care and 

cost effectiveness of care. 

The student regularly records data about generic aspects of chronicity by means of questionnaires and health and costs diaries. These aspects include the disablement process, self-management, mood problems, continuity of care and cost effectiveness of care. 

학생은 general practice나 병원이나 환자의 집에서 환자를 만날 수 있으며, 이 assignment는 학생 10명이 한 그룹으로 수행한다. assignment의 결과는 그룹 내에서 분석/평가된다. 리포트에 대한 코멘트를 받고 포트폴리오에 넣는다. YPP그룹은 일년에 8명 모이며, 각각의 모임은 90분정도 소요된다.

The student can see the patient in a general practice, in hospital or at the patient’s house. The assignments are prepared in groups of ten students. The results of the assignments are analysed and evaluated in the group. The reports are commented and included in the portfolios. The YPP-groups meet eight times a year, the meetings take 90 minutes.

가상환자 

SIMULATED PATIENT ENCOUNTERS (SPE)

매 년 시작시점에서 모든 학생들은 만성질환을 가진 가상환자를 만나게 된다. 학생은 SP의 주치의로서 역할을 하면서, 한 해동안 이 환자를 관찰하게 된다. 따라서 학생은 SP와 다음 약속을 잡아야 한다. 학생에게는 이런 것을 할 별도의 시간이 주어진다.

At the beginning of the year, all students (in pairs, one observer) see a simulated patient (SP) with a chronic disorder who has a complaint. The student has the role of the SP’s general practitioner and has to monitor the patient during the year. So, the student is expected to make new appointments with the SP. The students are given time to do this. 

매번 환자를 만나고 난 이후 SP는 학생에게 피드백을 준다. SP를 프로그램으로 짤 수 있기 때문에(programmability) 학생은 1년에 걸쳐서 SP를 수 회 이상 만나야 하며, 최소 4회는 만나게 된다. 환자에 대한 follow up을 위해서 실제 환자 기록이 만들어져야 한다.

After each contact, the SP provides feedback to the student. Because of the SP’s programmability, it is expected that the SP has to be seen several times in one year, probably with a minimum of four times (once every cluster). In order to follow the patient, a real patient record has to be made. 

학생들은 그 기록을 지속적으로 추적하고, 일년간 정보를 수집해간다. 이 정보에는 환자를 만나서 얻는 정보 뿐만 아니라, 검사결과와 specialist letter도 포함된다. SP와의 후속 만남을 통해 학생은 만성질환을 가진 환자를 대한다는 것이 작은 문제를 푸는 것이 아님을 알게 된다. SP와의 만남을 통해 학생은 YPP에서 실제 환자를 만났을 때 필요한 술기를 훈련할 수 있게 해준다.

The students keeps the record and adds information to it during the year. The record should not only contain information about the encounters, but also the possible (simulated) lab results and specialist letters. The follow-up contacts with the SP will show the students that dealing with patients with chronic disorders is more than just solving a small problem. The contacts with simulated patients enable the students to train the skills they need in the encounters with real patients in the year patient programme (YPP). 

SPE에서 다뤄지는 토픽은 YPP에서 다뤄지는 토픽과 동일하며, 한 해동안 학생들은 SP의 질병과 경험을 추적하게 된다. SP와 면담하는 것을 비디오 녹화(30분)하여 그룹의 모든 구성원과 함께 보면서 평가한다. 90분짜리 미팅을 9회 하게 된다.

The themes covered in SPE are the same as in the YPP. During the year the student thus follows the course of the disease and the experiences of the simulated patient. Video recordings of the simulated patient encounters (30 minutes) are watched and evaluated by all members of the group. There are nine meetings of 90 minutes each.

인터비전

INTERVISION

인터비전 미팅은 항상 SPE미팅과 바로 연결된다. 학생들은 SP환자와 실제환자 접촉에서 얻은 경험을 공유한다. 90분 미팅이 9회 있다.

The Intervision meetings are always directly linked to the SPE-meetings. Students exchange the experiences they have gathered from simulated and real patient encounters. There are nine meetings of 90 minutes.

주제 비판평가

CRITICAL APPRAISAL OF A TOPIC (CAT)

CAT은 임상활동의 과학적 접근을 연습하기 위한 것이며 다음의 단계를 밟는다.

CATs are meant to practise adopting a scientific approach to clinical acts (referral and test requests, choice of therapy). A CAT contains the following steps:

임상 시나리오 묘사

시나리오와 관련된 임상 질문 구성

검색 과정을 묘사 (자료 출처, 키워드, 배제 기준)

어떻게 과학적 연구를 구성하고 수행하는지 묘사. 연구의 질에 대한 평가

근거의 수준 표시

CAT과 구성된 결과에 대한 코멘트, 어떻게 적용될 수 있는가에 대한 코멘트.

Describe a clinical scenario (based on a patient of the OP encounter)

Formulate a relevant clinical question based on the scenario

Describe the search process with data sources, key words, and exclusion criteria for the articles found

Describe how a scientific study is set up and executed and assess the quality of the study

Indicate the degree of evidence

Comment on the CAT and formulate a conclusion about how the findings can be applied to the clinical scenario.

3학년의 CAT은 다음의 네 관련 영역이 있음.

진단

예후

치료/적응증/비적응증

관련 정책 평가

The CATs in year 3 refer to four clinically relevant domains:

Diagnostics

Prognosis

Therapy and (contra)indications

Evaluation of applied policy.

각 클러스터 기간동안 모든 학생들이 이 영역 중 하나 이상에 초점을 맞춘다. 즉 어떤 학생은 abdomen에서 진단을 하는 반면 다른 학생은 locomotor의 진단에 대해서 한다는 의미이다. 

During each cluster period the entire year group focuses one of these domains. This means that some students will do their CAT about diagnostics in a patient with intestinal complaints (Abdomen) whereas other students will do their CAT about diagnostics in a patient with shoulder complaints (Locomotor Apparatus). 

구성은 모든 학생에 대해서 동일하다.

an introductory lecture, 

a four-hour practical, 

one CAT the students set up as a group and 

one individual CAT. 

The organisation of this part of the programme is the same for all students: an introductory lecture, a four-hour practical, one CAT the students set up as a group and one individual CAT. 

CAT은 OPE를 기반으로 하며, 개별 CAT은 클러스터 포트폴리오에 포함되고 '과학자로서의 의사'의 역량을 평가하는데 활용된다.

The CATs are based on the patient encounters (OPE) in the student-centred outpatient clinic and in practice. The individual CAT is included in the cluster portfolio (see assessment) and is used to assess the competence level of the doctor as a scientist.

(출처 : http://members.home.nl/h.e.stoffers/UM_med_year3_2001.pdf)

The medical curriculum in Maastricht

Mirjam oude Egbrink, PhD

Programme Director Medical School FHML, University Maastricht

Maastricht 의학교육의 목표는 무엇인가?

What is our aim in medical education?

합리, 이론, 근거에 기반하며 최상의 학습 환경 구축을 통한 교육에 대한 과학적/학문적 접근 : 근거중심교육 

A scientific/academic approach to education, in which an optimal learning environment is created, which is based on rationality, theory and evidence: Evidence-based education

Three C's of education

Contextual

Constructive

Collaborative

Year 1 and 2

The tutorial group 

Composition : 8-10 students

- chair

- scribe

- tutor

Duration: 2 hours 

- 2 hours : 1 hour report +  1 hour new case prep

Frequency: 

- Twice per week

Year 3

Overview

• Chronic Disorders

• 4 clusters:

– Abdomen

– Locomotor system

– Circulation and Lungs

– Psychomedical problems and Mental Health Care

• Each 10 weeks, rotation

Group meetings

• 10 Students, 1 coach

• Once a week

• 4 hours

– 3 hours reporting

– 1 hour preparation

• 1-2 days later: patient encounter

• One week later: succeeding group meeting

Year 4 and 5

Structure: 

• start week: preparatory (theoretical) learning activities

• final week: evaluation, reflection, closure

Year 6

• Independent functioning and participation in health care and science

- Supervised independent work in a research environment : Thesis

- Supervised independent work in a clinical environment : Peer coaching, Built-in reflection moments

(출처 : https://www.google.co.kr/url?sa=t&rct=j&q=&esrc=s&source=web&cd=1&cad=rja&uact=8&ved=0CCsQFjAA&url=http%3A%2F%2Fwww.maastrichtuniversity.nl%2Fweb%2Ffile%3Fuuid%3Dea9102fa-3faf-40f3-8948-a9d7ac362911%26owner%3D6e9dd91c-0658-43ab-9c16-0f4c18360aa6&ei=8jAyU5bsAsbskgW83oGoCQ&usg=AFQjCNH7ohLGfq3O_-5J_ckpq4FZyvoKLw&sig2=Am1ZGZ4Nk_UhbwPSK1-2Kw)

Students’ perception of a modified form of PBL using concept mapping

JONAS INNIES ADDAE, JACQUELINE I. WILSON & CHRISTINE CARRINGTON The University of the West Indies, Trinidad and Tobago

우리가 사용한 PBL방법은 Maastricht의 7-step PBL방법을 기반으로 하고 있다. 7step을 요약하면 아래와 같다.

Our PBL method has been based on the Maastricht 7-step PBL method which has been well described (Schmidt 1983). In summary, the 7-step method we have been using comprises the following steps: 

(1) 잘 모르는 단어/구절/개념을 명확히 하기

(2) 답이 필요하거나 토론해야 하는 문제를 찾기

(3) 브레인스토밍을 하고, 가설을 세우기

(4) 토론한 주제에 대한 systematic inventory 만들기

(5) 학습목표를 나열하기

(6) 개별적으로 학습하기

(7) 다시 모여서 새롭게 얻은 정보를 공유하기

(1) clarifying unfamiliar terms, phrases and concepts in the clinical problem, 

(2) identifying issues in the problem that need to be answered or discussed, 

(3) discussing the issues in a free-flowing discussion (brainstorming) and generating hypotheses to explain the issues, 

(4) making a systematic inventory of the issues discussed, 

(5) listing learning objectives that are necessary to address gaps in knowledge, 

(6) private study of the objectives and related material, 

(7) reconvening as a group to discuss the objectives and relating the newly acquired information to the clinical problem. 

7단계 중 4단계에서는 mapping을 활용하고 있으나, PBL전체적으로는 그러한 방법을 사용하는 것은 아니다.

The fourth step of our conventional 7-step PBL method (systematic inventory) uses a form of mapping but that PBL method as a whole does not use much mapping.

concept map이 유용한 도구로서 보고된 바 있지만, 이러한 map을 토론의 '결과물'로서만 봄으로써 learning exercise 과정에서 학생그룹이 어떠한 과정을 겪는지에 대한 정보가 부족하다.

Although concept maps have been found to be a useful education tool in the health sciences (Weiss & Levinson 2000; West et al. 2000; Rendas et al. 2006; Gonzalez et al. 2008), the maps produced tend to be the end products of the group discussions, and lack information about the stages that the group go through during the learning exercise.

Students' perception of a modified form of PBL using concept mapping.

The students perceived the 5-phase method as promoting their passion for learning, and developing their cognitive, metacognitive and interpersonal skills

Impact of national context and culture on curriculum change: A case study (★★★)

MARIE¨ LLE JIPPES, MD, PHD1, ERIK W. DRIESSEN, PHD1, GERARD D. MAJOOR, PHD2, WIM H. GIJSELAERS, PHD3, ARNO M.M. MUIJTJENS, PHD1 & CEES P.M. VAN DER VLEUTEN, PHD1

1Department of Educational Development and Research, 2Institute for Education, 3Maastricht University, Maastricht, The Netherlands

Background: 

앞선 연구들은 한 국가의 문화가 의과대학의 교육과정 개혁에 있어서 큰 장벽이라는 것을 보여준 바 있다. 특히 Hofstede의 문화적 영역(cultural dimension) 중 '불확실성 기피'는 통합교육과정을 도입한 비율과 유의미한 음(-)의 상관관계가 있었다.

Earlier studies suggested national culture to be a potential barrier to curriculum reform in medical schools. In particular, Hofstede’s cultural dimension ‘uncertainty avoidance’ had a significant negative relationship with the implementation rate of integrated curricula.

Aims:

그러나 일부 의과대학은 그 나라의 높은 '불확실성 기피' 수준에도 불구하고 성공적으로 교육과정 변화를 이끌어낸 바가 있다. 이로부터 우리는 이런 질문을 할 수 있다. '어떻게 이들 나라는 '불확실성 기피'라는 장벽을 극복할 수 있었을까?'

However, some schools succeeded to adopt curriculum changes despite their country’s strong uncertainty avoidance. This raised the question: ‘How did those schools overcome the barrier of uncertainty avoidance?’ 

Method: 

오스트리아는 '불확실성 기피' 특성이 강하면서도, 모든 의과대학에서 통합교육을 도입하고 있다. 4개 의과대학을 면담함으로서 27가지의 핵심 변화 agent를 발견할 수 있었다.

Austria offered the combination of a high uncertainty avoidance score and integrated curricula in all its medical schools. Twenty-seven key change agents in four medical universities were interviewed and transcripts analysed using thematic cross-case analysis.

Results: 

우선, 국가적으로 강력한 법을 도입하고 학교의 자율성의 제한하는 것이 ''예외'를 인정하는 문화'', '잘못을 정부 측으로 돌리는 문화'를 억제하는데 기여했다. 새로운 법은 각 대학의 자율권을 '개혁을 촉진하는 것'에 주었다. 이것만으로는 부족할 수 있었겠지만, 변화에 대한 강력한 요구, 지지적이면서 지속적인 리더십, 선견지명을 갖춘 change agent가 중요한 것으로 보인다.

Initially, strict national laws and limited autonomy of schools inhibited innovation and fostered an ‘excuse culture’: ‘It’s not our fault. It is the ministry’s’. A new law increasing university autonomy stimulated reforms. However, just this law would have been insufficient as many faculty still sought to avoid change. A strong need for change, supportive and continuous leadership, and visionary change agents were also deemed essential.

Conclusions:

불확실성을 기피하고자 하는 특성이 강한 나라에서는 엄격한 입법을 통해 변화에 대한 저항을 막을 수 있다. 국가적 입법이 변화를 유도하고, 추가적으로 변화를 지지할 내부적 요인들이 더해지면 교수들의 반대도 극복될 수 있다.

In societies with strong uncertainty avoidance strict legislation may enforce resistance to curriculum change. In those countries opposition by faculty can be overcome if national legislation encourages change, provided additional internal factors support the change process.

Impact of national context and culture on curriculum change: a case study.

Globalization and the modernization of medical education

FRED C. J. STEVENS1 & JACQUELINE D. SIMMONDS GOULBOURNE2

1University of Maastricht, The Netherlands, 2University of the West Indies, Mona campus, Jamaica

Background: 

전세계적으로 교육자들과 학생들이 '효과적인 의학교육'이라고 생각하는 것에는 근본적인 차이가 있다. 그러나 의학교육에서 세계화가 용이한 '쉬운 공식'을 찾고 있었다.

Worldwide, there are essential differences underpinning what educators and students perceive to be effective medical education. Yet, the world looks on for a recipe or easy formula for the globalization of medical education.

Aims: 

여기서는 근대화의 운송자(carrier)로서 의학교육이 가지는 가정/주된 믿음/세계화의 영향 등을 보고자 한다.

This article examines the assumptions, main beliefs, and impact of globalization on medical education as a carrier of modernity.

Methods: 

문화적/사회적 구조를 찾고자 했다. 자메이카와 네덜란드의 두 의과대학에서 PBL에 대한 사례를 이용했다.

The article explores the cultural and social structures for the successful utilization of learning approaches within medical education. Empirical examples are problem-based learning (PBL) at two medical schools in Jamaica and the Netherlands, respectively.

Results: 

분석 결과, 사람들은 천성적으로 협동해서 일하는 것을 잘 하지 못했다. 효과적이고 효율적인 협력을 위해서는 그러한 문화를 만들어내기 위한 정교한 노력이 필요했다. 성공적인 PBL은 효과적인 의사소통기술에 기반하고 있고, 이는 현실을 이해하는데 필요한 공통의 지점에서 문화적으로 정의된다. 이러한 '공통성'은 존재하고 있는 것이 아니라, 명확하고 신중하게 만들어져야 한다.

Our analysis shows that people do not just naturally work well together. Deliberate efforts to build group culture for effective and efficient collaborative practice are required. Successful PBL is predicated on effective communication skills, which are culturally defined in that they require common points of understanding of reality. Commonality in cultural practices and expectations do not exist beforehand but must be clearly and deliberately created.

Conclusions: 

의학교육의 세계화는 디자인된 교수법을 도입하는 것 이상이며, 서구의 모델은 다른 환경에서 적용되기 위해서는 깊은 성찰과 숙고의 과정이 필요하다.

The globalization of medical education is more than the import of instructional designs. It includes Western models of social organization requiring deep reflection and adaptation to ensure its success in different environments and among different groups.

Results

2007년과 2008년, Maastricht 의과대학의 PBL은 학생들로부터 상당한 비판을 받았다. 학생들은 PBL이 그 근본 원칙에 따라 이루어지고 있지 않으며, 단순히 절차적인(ritualistic) 활동이 되어간다고 지적했다. 일부 학생들은 PBL의 유용성이나 적용가능성이 이미 시대에 뒤떨어졌다고 생각했다. 따라서 Bachelor학생들은 나름의 설문을 진행하여 의견을 모았고, 그 중 몇 가지를 아래에 기술하였다. 

In 2007 and 2008, PBL at the medical school of the University of Maastricht was highly criticized by students. Students felt that PBL was not carried out according to its essential principles and was at risk to become a ritualistic activity. Some believed that the usefulness and practicability of PBL was outdated. Therefore, students themselves conducted polling among all bachelor students to hear their opinions. These were some of the reported weaknesses of PBL (Stevens et al. 2010):

-그룹 상호작용은 거의 없으며 그룹 역학은 더 없다.

-학생들은 대개 개별적으로 학습하며, 그룹으로 학습하지 않는다. 이미 지정된 형식이 있는 경우 그룹학습은 ritualistic할 뿐이다.

-평가 단계에서 알아야 하는 것과 개별적으로 세우는 학습 계획이 맞지 않는다.

-학생들은 대체로 모국어로 된 권장 문헌과 인터넷을 사용한다.

-튜터는 그룹프로세스를 촉진하는 역할을 해야 하나, 학생들은 튜터의 전문가적 지식에 크게 의존한다.

– Little group interaction is used. Group dynamics hardly exist.

– Students largely work by themselves, not in groups. In areas where the prescribed formats are used, these are only ritualistic.

– A personal learning plan hardly fits to what students are expected to know at the assessments.

– Students largely use standard (recommended) literature and the internet, preferably in their native language.

– Tutors are required to only facilitate the group process. But students still heavily rely on the tutors’ expert knowledge. 

Mona 학생들과 마찬가지로 Maastricht학생들은 PBL시스템의 장점을 알고 있었다. 그러나 동시에 현장에서의 실패를 경험하고 있었다. Maastricht와 Mona의 학생들은 매우 달랐지만, 동시에 매우 비슷했다. 그룹역학이 작동하기 위해서는 적절한 문화적 구조와 적절한 사회적 구조가 필요했지만 이러한 기초요소가 없었던 것이다. 따라서 문화적 적절성의 문제, 구조적 한계의 문제는 여전히 남는다.

Just like the Mona students, Maastricht students are aware of the benefits of the PBL system but, at the same time, experience the practical failures. Obviously, the students in Maastricht and Mona are very different but, at the same time, very similar. They require the right cultural and social structural underpinnings to get the group dynamics going.

These basic ingredients are missing. So the question of cultural appropriation, structural limitations, and fit remains.

Discussion

From the comparison of PBL in Maastricht and at Mona, it is evident that in both contexts, the cultural underpinnings relating to systems and processes are/were not given due consideration for effective adaptation to the demands of PBL. 

The success of PBL is predicated on effective communication skills, which are culturally defined in that they require common signs and symbols and also common points of understanding of reality. 

Systemic problems are based on the culture of education, which includes the expectations of students as well as those of teachers and the school. This extends to the technological and structural support to make the model work as well as facilities to manage small groups.

Globalization and the modernization of medical education.

Early student-patient contacts in general practice: An approach based on educational principles

RAMON P. G. OTTENHEIJM, PAUL J. ZWIETERING, ALBERT J. J. A. SCHERPBIER, & JOB F. M. METSEMAKERS

Maastricht University, Maastricht, The Netherlands

Abstract

Background: Clinical teaching and learning is generally seen as an educationally sound approach, but the clinical environment does not always offer optimal conditions to facilitate students’ learning processes.

Aims: To show how insights on constructing a good learning environment for student-patient contacts in real practice can be translated into an undergraduate clinical general practice programme in Year 3 and to study its feasibility.

Method: Literature search, yielding starting points for the development of the new programme and questionnaire evaluation of the programme.

Results: Six starting points for a good learning environment for early student-patient contacts: continuing exposure to patients, transformation of experience into knowledge, active role of students, supervision and feedback, time and space for teaching and teacher training were translated into a the new programme. The evaluation showed that the programme was feasible and well received by students and GPs, although some improvements are possible.

Conclusion: In a curriculum with clear goals for early student-patient contacts, it is feasible to implement an early clinical programme in general practice based on educational principles.

Introduction

임상교육은 학부 의학교육의 중요한 요소이다. 조기 임상노출에 대한 언급은 1970년대로 거슬러 올라간다. 또한 최근의 많은 교육과정 개선이 학생들을 조기에 임상경험을 시키는 것을 목표로 하고 있다. 일반적으로 조기 임상 경험은 affective and cognitive 측면에서 긍정적인 효과가 있다. 또한 본격적인 임상실습에 잘 준비할 수 있도록 하며, 배우는 내용을 실제 환경에서 적용할 수 있게 되는 등 여러 장점이 있다. 그러나 이러한 중요성에도 불구하고 최선의 설계가 무엇인지에 대해서는 알려져 있지 않다.

Clinical education is a core component of undergraduate medical education, comprising early clinical experiences and clinical clerkships. Programme descriptions of early clinical experiences go back to the 1970s (Pittman & Barr 1977; Smith et al. 1977; Benor 1987). Many recent curriculum revisions have been aimed at promoting students’ early clinical experiences (Howe 2001; Whipple et al. 2006; Howe et al, 2007; Diemers et al. 2007; Hook & Pfeiffer 2007). Generally, early clinical experiences have positive effects on affective and cognitive outcomes and on knowledge and skill development. Further, they offer good preparation for clerkships. More specifically, they provide an authentic context for learning, help students develop clinical ways of thinking, support students’ learning of biomedical and behavioural/social sciences and offer knowledge that cannot be learned from books (Dornan & Bundy 2004; Dornan et al. 2005). However, despite the fact that the importance of early clinical experiences is underpinned by an evidence-based set of learning outcomes, little is known about the best way to construct such experiences

임상실습에 대한 연구문헌을 살펴보면 임상환경이 항상 최선의 학습환경은 아님이 드러난다. 지나친 다양성과 예측불가능성, 불연속성 등의 특징이 있기 때문에 일차의료진료환경에서 일대일로 가르치는 것이 효과적인 임상교육을 위해서 더 좋을 수도 있다.

Research on clerkships has shown that the clinical environment is not always the best setting to enhance students’ learning processes. Students’ learning experiences are characterized by variability, unpredictability, and lack of continuity (Remmen et al. 2000; Murray et al. 2001; Irby & Bowen 2004). Primary care settings and teaching based on one-to-one contacts may be environments most likely to fulfil criteria for effective clinical teaching (van Leeuwen 1995; Gordon et al. 2000).

2001년 Maastricht의과대학의 6년 교육과정의 revision이 있었고, 그 목적 중 하나는 초기 임상경험을 강화하는 것이었다. 

In September 2001, a revision of the six-year undergraduate medical curriculum of Maastricht University was launched. One of the aims was to intensify early clinical experiences in different practice settings. Until 2001, the Department of General Practice delivered two undergraduate courses based on student-patient contacts: the early clinical Adoption Programme and a clerkship in Year 6 (Martens & op ‘t Root 1992; Crebolder & Metsemakers 1994; van Bokhoven et al. 1998).

Method

우리는 조기임상경험을 '임상실습 전에 실제 환자와 실제 임상 상황에서 접촉함으로서 학습과정을 촉진하는 경험'이라고 정의했다.

We defined early clinical experience as pre-clerkship experiences with authentic patient contact in a clinical context that enhances the process of learning (Dornan et al. 2005)

1단계 : 배경정보 - 문헌 검색

Step 1 Background information

We searched Medline and Psycinfo for articles published after 1970, using the keywords: medical education, undergraduate, programmes, family practice or general practice, and supervision.

2단계 : 프로그램 기술

Step 2 Description of the programme

This step involved translation of the starting points resulting from step 1 into the new programme.

3단계 : 프로그램 평가

Step 3 Evaluation of the programme

We evaluated the first three years of the new programme by a questionnaire survey among the GPs and students participating in the programme.

Results

전 임상실습 교육과정 중 실제 진료환경에서 학생-환자간 효과적인 학습환경을 만드는 방법

Step 1: How to construct an effective learning environment for pre-clerkship student-patient contacts in real practice

1. 조기 환자 접촉의 중요성 : 환자에 대한 지속적 노출이 중요하다.

1. The importance of early patient contacts

지식의 구조화와 장기기억에 Practical experience의 중요성

학생이 illness script를 쓰는 것이 중요

조기에 폭넓은 문제에 대해 다양한 환자를 만나는 것이 중요

There is evidence that practical experience is a prerequisite for the development of medical expertise, based on cognitive psychological theories regarding clinical reasoning and how knowledge is structured in long-term memory (Bordage & Lemieux 1991; Schmidt & Boshuizen 1993; Custers et al. 1998; van de Wiel et al. 1999). It is important for students to develop illness scripts, which consist of pathophysiological knowledge, information about physical, mental and social consequences of disease and the situation in which illness develops. These structures of expert knowledge result from continuous exposure to patients and thus require extended practice in professionally relevant contexts. This underscores the crucial importance of students seeing, at an early stage, multiple patients with a wide range of problems in a professionally relevant context (Dolmans et al. 2005). Starting point A: Continuing exposure to patients.

2. 효과적인 임상교육과 임상학습

2. Criteria for effective clinical teaching and learning

Whilst we are able to describe the settings in which students learn, we are still struggling to answer the question of ‘how’ learning comes about. 

학습 사이클 : Kolb의 경험학습이론. 다양한 사례로부터 얻은 insight가 지식을 illness script로 변환시킨다.

Learning cycle. Kolb’s experiential learning theory asserts that learning occurs through interactions between persons and their concrete experiences (Kolb 1984; Scho¨n 1990). The essence of learning is transformation of experience into knowledge in a cycle which starts with a concrete experience, such as a patient encounter, followed by reflection on that experience, which in turn leads to conceptualizations and generalizations, which are then tested in new situations at which point the cycle starts again. Experiential learning may be enhanced when learners become aware of the consequences of their actions as a result of feedback and inquiry. Generalisation of insights from many different cases can restructure knowledge in memory into illness scripts (Smith & Irby 1997). Starting point B: Transformation of experience into knowledge

학생의 능동적 역할 : 관찰은 초기 단계에서, 매우 제한된 기간동안만 효과적이다. 더우기 정교한 계획과 촉진적 교수가 필요하다. 환자를 독립적으로 보는 것이 중요하다.

Active role of students. What type of practical experience do students need to develop their illness scripts and basic skills? Several teachers think it is sufficient for students to observe clinical situations to achieve the desired exposure. However, observation is only effective in early stages of training, providing preparation and debriefing take place, and even then only for a limited period of time. Students will inevitably get bored and their enthusiasm will fade. Moreover, it requires careful planning and facilitative teachers (Kachur 2003). Thus, students should not remain passive observers for long. Active approaches are ‘hot seating’, with a student leading (a part of) a consultation, and independent patient encounters, in which a student first sees a patient alone in a separate room before being joined by the teacher. Seeing patients independently is the most valued setting for achieving positive learning outcomes (Lawrence et al. 1999; Spencer 2003; Stark 2003). Starting point C: Active role of students.

감독과 피드백 : 감독은 환자outcome에 긍정적인 효과가 있으며, 감독이 없으면 환자outcome에 악영향을 끼치게 된다. 또한 감독관은 임상적으로 유능하면서 많은 지식을 가지고 있어야 하고, 교수능력과 대인관계 능력이 좋아야 한다. 피드백은 감독하는데 있어서 중요한 요소이나 의학교육에서 피드백은 표준적이지 못하다.

Supervision and feedback. Supervision has positive effects on patient outcomes and lack of supervision is harmful to patients. Supervision is key to the success of clerkships (Kilminster & Jolly 2000; Dolmans et al. 2002). Important features of supervision are continuity over time, supervisees’ control of the content of supervision and some reflection by student and supervisor. Effective supervisors give their supervisees responsibility for patient care and offer

opportunities to carry out procedures and review patients, involvement in patient care, guidance, and constructive feedback. They should also be clinically competent and knowledgeable and have good teaching and interpersonal skills (Kilminster & Jolly 2000; Cottrell et al. 2002). Feedback is an essential component of supervision (Rolfe & Sanson Fisher 2002). Unfortunately, the frequency and quality of feedback in medical education are not always up to the mark (Schamroth & Haines 1992; Paul et al. 1998). Feedback should be directed towards behaviour that is amenable to change and be specific rather than general. The needs of the receiver as well as the giver should be considered. Also, feedback should be given timely, i.e. as close as possible to the event, and selectively address one or two key issues rather than too many all at once (Irby 1994; King 1999). Starting point D: Supervision and feedback.

3. 현실적 문제점

3. Practical points

시간과 공간의 제약 : 여러 의사들이 교육과 관련해서 언급하는 문제

Time and space. Most doctors recognize that for clinical teaching the availability of time and space may pose significant problems. Therefore, ample opportunities and acceptable incentives, such as financial reward, are important issues for doctors (Hartley et al. 1999; Haffling et al. 2001; Stark 2003). Given scarcity of time, logistical matters must be dealt with adequately (Hartley et al. 1999). An example of a model of effective and efficient use of time and integration of teaching into day-to-day routine is the ‘one-minute preceptor’ (Spencer 2003). Starting point E: Time and space for teaching. 

교수 훈련 : 학생과 교수가 임상 교육의 내용/스타일/세팅에 대해서 항상 잘 맞는 것은 아니다.

Teacher training. Students and clinical teachers are not always in agreement with regard to content, style and setting of clinical teaching (Stark 2003). Clinical teachers are not fully aware of what to expect and what not to expect from students and may be uncertain about how to give feedback and how to assess. In early patient contacts they are not merely preceptors but they take on the mentor role with a strong focus on supervision and feedback. Therefore, teaching should also include time for preparation and teacher training (Irby 1995; Gordon et al. 2000; Haffling et al. 2001; Stark 2003). Starting point F: Teacher training.

2단계 : 3학년 프로그램의 일반

Step 2: General practice programme in Year 3

The starting points (left column Table 1) resulting from step 1 were used in designing the new GP programme in Year 3 of the new Maastricht curriculum. Within the context of these encounters theory and practice are addressed in an integrated manner. Thus starting points A-D are guaranteed (Figure 1).

After the encounter, they write a structured ‘SOAPEL’ report (subjective, objective, assessment and plan (SOAP) supplemented by elaboration and learning goals)

GP를 대상으로 일 년에 두 차례의 워크숍을 수행함.

Twice a year workshops are offered to inform the GPs about the curriculum and the content of the clinical general practice programme. In the workshop, GPs are instructed about how to fit the programme into their daily practice routine and specific topics are addressed (F) (Table 2).

Step 3: Programme evaluation

The questionnaire items are presented in Table 1. Table 3 shows the response rates and descriptive statistics.

Conclusion and discussion Our findings suggest that early student-patient contacts do indeed enhance learning and integration of theory and practice, and are sustainable (Diemers et al. 2007; Howe et al. 2007).

In designing this programme, we were mindful of Mainhard’s conclusion about the Maastricht Adoption Programme (Mainhard et al. 2004)

Early student-patient contacts in general practice: an approach based on educational principles.

In a curriculum with clear goals for early student-patient contacts, it is feasible to implement an early clinical programme in generalpractice based on educational principles.

Changing face of medical curricula

Roger Jones, Roger Higgs, Cathy de Angelis, David Prideaux

네덜란드에서는 과부하가 걸린 교육과정을 감축하고, 더 흥미를 유발할 수 있는, 적극적인 형태의 교육을 하라는 정부의 압박에 따라 전통적 교육과정과 PBL교육과정이 같이 이뤄지고 있다. 소규모의, 문제중심학습 그룹에 기반을 둔 통합교육과정은 첫 4년간은 공통적이다. 일부 학교들은 학생들의 술기 학습을 위해서 시뮬레이션 기술을 이용하고 있는데, Limburg, Maastricht등의 의과대학이 이러한 능동적 학습 전략을 적용하는데 앞장서고 있다.

In the Netherlands, both traditional and problem-based curricula are taught in response to pressure from the government to reduce overloaded curricula, and to create more attractive and active forms of teaching. Modular, integrated courses based on small, problem-based learning groups, are common in the first 4 years. Some schools also make extensive use of simulation techniques to help students master professional skills; the medical school of Limburg, Maastricht, has had a leading role in the development and application of these active learning strategies.28

Changing face of medical curricula.

Medical curriculum reform in North America, 1765 to the present: a cognitive science perspective. 

Papa FJ, Harasym PH.

1765년 이후로, 북미의 의과대학에서는 다섯 개의 주요한 교육과정 개혁 움직임이 있었다. 여기서는 각각에 대해서 그것의 기저에 있는 교육방법과 원칙, 내재적 한계, 극복을 위한 움직임 등을 보고자 한다. 이러한 개역 움직임의 원동력을 살펴보면 공통의 주제가 드러난다. 지식기반구조(knowledge-base structure)와 인지과정(cognitive process)에 대한 관심과 이해, 그리고 전문가와 초보자의 구분에 대한 관심과 이해이다. 이렇게 반복적으로 나타나는 주제들은 의학교육자들이 연구문헌, 연구방법, 인지과학의 이론적 관점들을 잘 활용해야만이 미래의 개혁을 효율적/효과적으로 이끌 수 있음을 보여준다. 저자들은 여기서 논의된 주제들과 관점들이 더 확장되고, 촉진되어 교육자들이 앞으로 21세기 의학교육 개혁 움직임을 만들어나가는데 도움이 되기를 바란다. 

Medical curriculum reform in North America, 1765 to the present: a cognitive science perspective.

The challenge of reform: 10 years of curricula change in Italian medical schools

HUON SNELGROVE, GIUSEPPE FAMILIARI, PIETRO GALLO, EUGENIO GAUDIO, ANDREA LENZI, VINCENZO ZIPARO & LUIGI FRATI

First and Second Faculty of Medicine, Sapienza University of Rome, Italy

진단검사와 피드백 Progress tests and feedback

10년 전, 이탈리아의 일부 교수들의 European comparative study를 한 이후로, 이탈리아는 학생의 functional knowledge 평가를 위하여 Maastricht의 모델을 본떠서 National Longitudinal Progress Test 를 도입했다. 이 시험은 학생과 교사들에게 피드백을 줄 수 있는 거대한 자원이다. 학생들은 현재 같은 학년내에서, 과목별, 국가 순위를 받게 된다. 이 시험이 다른 시험들과 함께 EU 면허시험의 한 부분으로 쓰일지는 두고 봐야 할 것이다.

After early experimentation in some Italian medical faculties in a European comparative study over 10 years ago (Albano et al. 1996) Italy introduced a National Longitudinal Progress Test based on the Maastricht model in 2006 to assess the functional knowledge of students. Under the auspices of the National Committee of Medical Degree Course Heads this could become a systematic nationwide instrument. The test provides a huge resource for feedback to students, teachers and for internal and external evaluation (Feletti et al. 1983, van Der Vleuten et al. 1996; Tenore 2008). Students currently receive feedback on their rankings compared to class, subject area and national rankings. Whether the progress test in combination with other test formats, will be used as part of a wider EU licensure exam, as its authors had originally speculated, remains to be seen (van Der Vleuten 1990; Albano et al. 1996).

The challenge of reform: 10 years of curricula change in Italian medical schools.

The Association of Faculties of Medicine of Canada

SUPPLEMENTAL REPORT OF THE INTERNATIONAL COMPARISONS - THE NETHERLANDS

JAY ROSENFIELD, MD

NOVEMBER 2008

2. Organization of medical education in the Netherlands:

네덜란드의 의과대학 시스템은, 대부분 고등학교를 졸업하고 바로 입학하게 되는데, secondary school 학생은 요구조건인 고등학교 교과과정을 마치고 국가시험을 치러야 한다. 네덜란드에 독특한 점은, 그렇게 시험을 보고 나서 학생은 의과대학에 입학하기 위해서 국가 가중추첨(weighted national lottery procedure)에 지원하게 된다는 점이다. 그러나 매우 고득점을 받은 사람은 바로 의과대학에 들어갈 수 있다. 두 번째 입학 방법은 미국 의과대학과 유사한데, Utrecht와 Maastricht에 존재하는 방법으로서 의과학분야에서 학사를 받은 사람이 4년제 의과대학 프로그램에 입학하는 것이다.

The Dutch medical school system, which is predominantly direct entry from high school, requires that secondary school students finish a pre-requisite high school curriculum and take a national examination. Unique to the Netherlands, students then apply to a weighted national lottery procedure for entrance selection to medical school. However, those with very high scores on the national exam may freely enter the medical school of their choice. A second entry route, similar to the North American system, exists at two schools, Utrecht and Maastricht, and allows for graduate entry into a four year medical programme for those with a prior bachelor diploma in biomedical sciences.

국가가 입학 정원을 조정하며, 현재는 매년 2850명이 입학한다. 그러나 지원자는 항상 이 정원을 넘어서서 30~50%의 지원자가 탈락한다. 탈락하는 이유는 추첨에서 떨어졌거나 기준에 맞지 않기 때문이다. 학생들은 교육의 질을 자세히 살피고 의과대학을 선택하기 보다는, 대부분 secondary school학생을 위해서 열리는 미팅에서 받은 인상에 따라서 이루어진다. 네덜란드의 대중들은 대개 대부분의 학교들이양질의 교육을 제공한다고 믿고 있으나, 사실 그렇지는 않다. 대학들이 생각하는 것에 비해서 지역적 요소가 차지하는 비중이 크다.

“The Government regulates the enrolment number, currently 2850 students per year (Table 1). As the interest among high school graduates has always exceeded this numerus fixus, 30 to 50% of applicants are turned down, either because they fall out of the lottery, or they do not meet selection criteria. The choice of a medical school is mostly based on impressions from organised meetings for secondary school students, more than from thorough investigation of the educational quality; the Dutch public usually trusts that all schools deliver adequate education which in itself is not untrue. Geographical convenience is a more important determining factor than universities would like to believe.

네덜란드의 의과대학은 6년제이며, Bologna framework를 따른다(학사+석사). 미국과 달리 네덜란드 학생들은 정부에서 상당한 생활비와 교육비 지원을 받는다. 많은 학생들이 용돈을 위해 부업을 한다. 매우 소수의 학생만이 빚 없이 졸업하게 된다. European 근무시간 지침에 따라서 근무시간은 매우 제한적이며, 의과대학에서 졸업한 학생들은 졸업후 교육에 지원하게 되는데, 대학병원이 주로 이를 담당함에도 학생의 지원은 대학의 관할 밖에 있다.

The medical program in the Netherlands is six years in length, and follows the Bologna framework. (bachelor plus master) Unlike North America, Dutch students receive significant government financial grants for their living expenses and education. Many students also work in jobs to make extra money needed. Very few students graduate with any significant debt. The work week is limited in hours as per the European work-time directive. Most students who graduate from medical school apply for postgraduate training, which is not under the jurisdiction of the Universities, though the University Medical Centres play a major role in the delivery of such training.

주요 이슈들

대학과 병원의 거버넌스 문제 : 학장은 병원에서 부원장을 맡고 있으며, 병원장은 부학장을 맡고 있다.

• Governance -integrated structures between academic health science centre and university— Dean is Vice-President of Hospital and Hospital President is Vice-Dean of Faculty— integrated, small and nimble governing board (Maastricht)

의과대학 시작과 함께 임상 실습을 하는 것(예컨대, 생리학 학습을 위해서 첫 해에 응급의학과 로테이션을 함)

• Introduction of clinical training right at beginning of medical school (eg emergency rotation in first year to demonstrate physiology) (Maastricht)

모든 학생들이 연구 프로젝트를 이수함

• All students complete research scholarly project (Maastricht)

학생이 교육과정 개발에 파트너로서 참여

• Students as partners in curriculum development (Maastricht)

(출처 : http://www.afmc.ca/future-of-medical-education-in-canada/medical-doctor-project/pdf/Netherlands%20Comparison%20report.pdf)

신뢰도 : 한 척도가 측정하고자 하는 것을 일관되게 반영하고 있는가

신뢰도에 대해서 생각해볼 수 있는 한 가지 방법은, 한 사람이 서로 다른 두 시점에 시험을 보았을 때 동일한 점수를 받아야 한다는 것이다. 

다른 방법으로 split half reliability가 있는데, 임의로 반으로 나눠서 두 개의 절반을 비교하면 그 둘이 같거나 거의 같아야 한다는 것이다. 그러나 이 방법의 문제점은 어떻게 반을 나누느냐에 따라서 결과가 달라질 수 있다는 것이다. 이 문제를 해결하기 위해서 Cronbach는 loosely equivalent to splitting data in two in every possible way and computing the correlation coefficient for each split을 사용했다. 이 값의 평균은 Cronbach's alpha와 같은데, 흔히 신뢰도의 척도로 사용되는 것이다.

두 가지 버전이 있는데 한 가지는 normal이고 다른 하나는 standardized version이다. normal은 한 척도에 속하는 아이템의 총합이 그 척도에 대한 하나의 대표값을 이루는 것이다. 이 경우 standardized alpha는 적절하지 않다. Standardized alpha는 합해지기 전에 한 척도에 속하는 아이템들이 standardized 될 때 사용한다.

Cronbach's alpha의 해석.

흔히 0.7~0.8이 수용가능한 Cronbach's alpha라는 말을 듣곤 할 것이다. 이것보다 값이 크게 낮다면 신뢰할 수 없는 척도라고 할 수 있다. Kline은 비록 일반적으로 0.8이 수용할 수 있는 수준이긴 하나, 지능검사 같은 인지적 검사에서는 0.7을 쓸 수도 있다고 말했다. 또한 psychological construct에 대해서는 심지어 0.7보다 작을 수도 있다고 주장했다.

또한 Cortina는 alpha의 값이 그 척도에 몇 개의 아이템이 있느냐에 따라 달라지기 때문에 이러한 일반적인 가이드라인은 유의해서 사용해야 한다고 지적했다.

alpha는 또한 '역으로 채점되는 아이템'에 의해서도 영향을 받는다.

신뢰도 분석에서 심지어 이런 'reverse scored item'은 Cronbach's alpha를 음수로 만들 수도 있다.

따라서 그러한 문항이 있다면 그 문항이 계산되는 방식을 바꿔서 다시 계산해야 한다.

Factor Analysis 편에서 orthogonal rotation을 사용하여 4개의 subscale을 만든 바 있다.

Scale if item deleted를 체크하면, 그 아이템이 지워졌을 경우 alpha가 어떻게 변하는지 보여준다. 만약 설문이 reliable하다면 하나의 아이템이 지워졌다고 해서 전체의 reliability에 크게 영향을 주면 안된다.

Corrected Item-Total Correlation은 아이템과 총점 사이의 correlation울 보여준다. 신뢰성이 있는 척도라면 모든 아이템은 총합 점수와 correlate해야한다. 만약 0.3보다 작은 것이 있다면 그 특정 아이템이 잘 correlate하지 않는 다는 것을 말하고, 그 아이템은 제거되어야 한다.

마지막으로, 가장 중요한 것은 아래 나와있는 alpha는 Cronbach's alpha로서 overall reliability of the scale을 뜻한다. 

만약 어떤 아이템을 제거해야 할 필요가 생기면 factor analysis를 다시 수행하는 것이 좋다.

Cronbach's alpha를 보고하는 법은 간단하다.

~은 good internal consistency를 가지는 것으로 나타났으며, alpha=.82이다.

(부가적) 모든 아이템은 포함시킬 가치가 있으며(worthy of retention), 10번 item을 삭제시 alpha가 가장 많이 증가하였지만, 0.005수주이었다. 모든 아이템은 총점과 일정정도의 상관관계를 가졌다. (r 최저값 = .40)

(출처 : http://www.statisticshell.com/docs/reliability.pdf)