교육자로서 의사의 전환적Transformative 전문성개발(Acad Med, 2003)

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

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

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

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

배경

BACKGROUND

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

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

• interactive whole-group presen- tations and exercises,

• problem-based learning,

• observations,

• reflective use of journals, and

• discussion in large and small groups.

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

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

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

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

• the definition of goals,

• institutional problem to be addressed,

• the role of stakeholders,

• barriers to implementation,

• required resources and

• evaluation method to determine measures of improvement.

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

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

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

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

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

• 프로젝트의 강점merits perceived merits of the proposed project, and

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

방법

METHOD

다음의 성과는 측정

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

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

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

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

• 개인의 변화 Individ-ual change was defined as

• self-reported changes in teaching behaviors,

• aca-demic productivity,

• academic advance-ment, and

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

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

• the parti-cipants’ changes in teaching behaviors,

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

• obtaining grant funding.

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

• maintaining ties to program participants and/or

• faculty members and outreach to others. 

RESULTS

고찰

DISCUSSION

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

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

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

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

개별화된 자문과 집중펠로우십이 효과가 있음

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

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

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

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

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

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

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

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

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

왜 성공적이었을까?

Why is this professional development program successful? 

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

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

근무지에서의 교육실천공동체: 교수개발프로그램 평가(Med Teach, 2015)

Communities of teaching practice in the workplace: Evaluation of a faculty development programme

MARIE-LOUISE SCHREURS, WILMA HUVENEERS & DIANA DOLMANS

Maastricht University, The Netherlands

도입

Introduction

교수개발은 사고방식과 실제 교육행동을 변화시키는 쪽으로 teacher의 지식/술기/개념을 강화하고 확장하기 위한 활동의 coherent sum이다.

Faculty develop- ment involves

the coherent sum of activities targeted at strengthening and extending the knowledge, skills and con- ceptions of teachers in a way that will change their way of thinking and their actual educational behaviour (Fenstermacher & Berliner 1985).

최근 교수개발의 초점은 개개인 수준에서 그룹 수준으로 변화했다.

Recently, the focus of faculty development has shifted from an individual level to a group level.

• group learning by a team of teachers을 강조
  Steinert (2010), for instance, discerned a movement away from individual experi- ences to group learning by a team of teachers.

• 그룹 단위에서의 FD를 강조함. 두 종류의 실천공동체
  O’Sullivan and Irby (2011) also laid a greater emphasis on FD at group level. They distinguished between two communities of practice:

• one created between participants in FD programmes,

• the other being a community of teaching practice in the workplace (classroom or clinic) where the teaching is actually effected.

그러나 모든 실천공동체에 대해서 '참여와 학습이 사회적 요인에 달려있다hinge on'이라는 사실은 불변이다.

참여를 향상시키는 요건

Yet, what holds true for any community of practice is that participation and learning hinge on social factors. By

• 친화적inviting 환경 creating an inviting environment,

• 가이드 제공 providing guidance and

• 개인의 관여/관계 장려 encouraging personal engagement, relationships within the community

can enhance participation

참여에는 다음이 영향을 미친다.

Also,

• 직무구조 work structure,

• 시간압박 time pressure,

• 직무량 workload and

• 직무흐름 work flow

all affect participation.

근무지에서의 멘토링과 코칭

Mentoring and coaching in the workplace

Doppenberg  등은 동료와 협력적으로 수행하는 교수-학습 활동의 유형을 연구하여서, 상호교환Exchanging, 경청listening, 평가evaluating이 가장 흔히 보고되는 활동

Doppenberg (2012) provided an overview of categories of teacher-learning activities in collaboration with colleagues. For each activity listed, she investigated the frequency of its occurrence within different collaborative settings. Exchanging, listening and evaluating emerged as the activities most frequently reported.

Steinert 등은 FD가 personal and professional growth 를 가능하게 하며, 교수들이 이것을 받아들이고, 자신의 니즈와 맞을 때 더 참여할 가능성이 높다고 했다. 또 다른 내적동기부여 요인으로는 교육과 자기발전self improvement을 중요하게 생각하는 것appreciation, 네트워크의 기회 등이 있었다.

Steinert et al. (2010) by extension argued that FD enables personal and professional growth and that faculty might be more likely to participate whether they appreciated this and considered it relevant to their needs. Other intrinsic motiv- ations could be their appreciation of teaching and self- improvement, coupled with the opportunity to network.

비슷하게, Lave and Wenger 는 실천공동체의 성공에 있어서 관계과 네트워크의 중요성을 강조하였다. 커뮤니티 내에서의 관계 뿐 아니라 외부 네트워크에 참여하는 것도 중요함.

In a similar vein, Lave and Wenger (1991) stressed the importance of relationships and networks to the success of a community of practice, and they deemed importance of both the relationships forged between community members and participation in external networks.

교육네트워크에 참여하는 것은 (1)동료와 교육적인 이슈에 대해서 상호교환 및 컨설팅을 하는 것exchanging and consulting colleagues과 같이 비공식적 방식으로 , 또는 (2)working group이나 전문가 미팅, 컨퍼런스 등과 같이 공식적으로 참여하는 것이 있다.

Participation in educational networks can occur in an informal way by exchanging and consulting colleagues about educational issues or more formal by collaborating in a working group or taking part in a professional meeting or educational conference.

근무지의 조직/시스템/문화

Organization, systems and culture in the workplace

Teunissen 는 실천으로부터 배우는 것learning from practice 이 사람들로 하여금 자신의 특정한 맥락에서 작동하게 만들려면 어떻게 수행하고/생각하고/상호작용해야하는지를 배우게 해준다. 동시에, learning from practice는 고도로 맥락적인 특성이 있어서 그 자체가 challenging한 교육환경이다.

Teunissen (2014) argued that learning from practice enables people to learn how to perform, think, and interact in ways that work for their specific context. At the same time, however, the highly contextual nature of learning from practice makes it a challenging educational environment.

조금 다른 각도에서 Eraut 는 관리자적 역할managerial role의 중요성을 강조했는데, 이 역할이란 상호지지와 학습의 문화를 만드는 것이다. Manager는 이 역할을 숙련된 worker들과 공유해야 하며, 이것은 distributed leadership의 한 형태이다. 이러한 능력이 직무에 기술된 것을 넘어서는 workplace learning과 문화에 영향을 준다.

From a different angle, Eraut (2007) asserted the import- ance of the managerial role, which is to develop a culture of mutual support and learning. Managers should share this role with experienced workers and this implies some form of distributed leadership. In this capacity, they have a major influence on workplace learning and culture that extends far beyond their job descriptions.

관리자적 역할 외에도 조직의 학습 분위기 역시 중요한 변인이다. Lave and Wenger 는 커뮤니티는 'a shared repertoire of common resources'가  필요하다고 했다. 더 나아가서, 반복적인 활동의 패턴으로부터 생성되는 ‘‘shared and negotiated system of socially and culturally meaningful structures’’ 가 있으면 더 좋다. Teunissen 는 이것을 가지고 변화에 저항하는 안정된 근무환경의 구조를 refer했다.

Beside the managerial role, also the learning climate of the organization is an essential variable (van Rijdt et al. 2013). Lave and Wenger (1991), for instance, argued that a community requires a shared repertoire of common resources, including language, stories and practice. What is desirable, moreover, is a ‘‘shared and negotiated system of socially and culturally meaningful structures’’ resulting from recurrent patterns of activities (Teunissen 2014). By this, Teunissen referred to stable structures in the workplace environment that are resistant to change.

근무지에서의 과제와 활동

Tasks and activities in the workplace

• Doppenberg (2012) posited that collaboration in teams can foster teaching learning, for instance by giving teachers the shared responsibility for an educational task, or by imple- menting a new educational approach.

• Lave and Wenger (1991) also stress the importance of the shared activity of newcomers at the workplace in the learning process.

• Fuller and Unwin (2003) describe the process from peripheral to mainstream participation in an organization. Working alongside and interacting with experienced colleagues leads to learning by engagement into the practices of the community.

• Handelzalts (2009) hailed the benefit of collaboration in his study into the way teachers collaborate in teams for the purpose of designing a new curriculum;

연구의 초점

Focus of the study

연구질문

Research question

UTQ course라고 부름.

As previously mentioned, the FD programme under scrutiny in this study concerns a so-called UTQ course, which forms part of the opportunities for faculty development offered by the FHML at Maastricht University in the Netherlands. The programme is intended for teachers and for faculty members who want to improve their educational skills and expertise. 

• 프로그램의 총 기간은... The full UTQ programme spans 

• 코칭스킬을 훈련받은 코치들은.... The coaches, who had been trained in coaching skills, 

• 과정이 진행되는 동안 포트폴리오 작성해야... Throughout the course, participants compile a portfolio

UTQ역량의 개발은 참가자의 현재 역량, 학습목표, 실제 교육상황에서의 학습 등에 달려있음. 다섯 달 동안 다섯 차례의 의무 트레이닝이 있음

The development of UTQ competencies depends on participants’ present competencies, learning objectives and their learning in authentic settings in educational practice. Over a period spanning five months, participants partake in five compulsory training days, 

대상

Subjects

총 102명의 선생 중 23명의 선생이 응답. 임상/기초/사회과학 분야로 나뉨. 24명이라는 숫자는 미리 정해진 것이었으며, 4회 정도 포커스그룹 인터뷰를 하면 saturation될 것이라고 기대되었음. 전화로 모집하였으며, set text를 읽는 표준화된 방식으로 연구에 대해서 설명해줌.

Respondents were 23 teachers (10 women, 13 men) from the Maastricht University FHML, selected by purpose sampling (Stalmeijer et al. 2014) from a total of 102 teachers who attended and successfully completed the UTQ programme. Participants from three clusters of departments with clinical, biomedical or social sciences backgrounds were proportion- ally represented in the sample. The number of 24 subjects was determined a priori. Saturation was expected to take place after four focus groups. We recruited the subjects by telephone and informed them about the study in a standardized way by reading a set text.

1명이 focus group에 참여하지 않았음. 교육경험은 2~20년.

One subject selected did not join the focus group session. Their prior experience of teaching ranged from two to 20 years, with eight of the teachers having five or fewer years of experience.

도구

Instrument

포커스그룹에 대한 설명

For this evaluation study, we used the focus group method. According to Morgan (1998), focus groups of six to eight participants are useful for evaluation research to explore topics that are poorly understood. The group discussions create a process of sharing and comparing among the participants and they explore the contexts in which they operate for us as researchers. We convened four focus group sessions of two hours each with six participants, which were facilitated by a moderator and assistant moderator, to discuss and explore the relevant themes. Both were skilled in group dynamics and the subject matter under discussion and had a background in educational psychology. The role and responsibilities of the moderator and assistant moderator were consistently divided across all focus groups (Stalmeijer et al. 2014). 

The format was semistructured and departed from four questions about coaching, networks, organization and activities in the workplace that guided the discussion; the questions were derived from the framework of O’Sullivan and Irby (2011) (Appendix). We discussed the questions in the research team and we pilot tested them in the first focus group with the participants. The moderator systematically went through the questions and gave time to the participants to collect and express their thoughts. Participant verification took place by summarizing the main results from each question, before moving on to the next. After the session the moderators took time to debrief, compare field notes and discuss first impressions and highlights. These steps in systematic focus group interviews were described by Krueger (1998). 

분석

Analysis

The sessions were taped and summarized by a research assistant. All participants were informed about the use of the tapes and the confidentiality of the data and were explicitly asked for agreement of the procedure. Two researchers(Marie-Louise Schreurs & Wilma Huveneers) independently analysed the summaries.

• To trustfully conduct the process of analysis, we started to analyse the first focus group, by reading the transcript carefully and coding relevant quotes to identify key themes independently.

• We compared the results, resolved discrepancies by discussion and fine-tuned our strategy for further analysis of all four groups.

• Afterwards, we had a comparison discussion and selected the relevant quotes in our research team to verify the results. 

The process of analysis has been carried out systematically following the steps identified by Krueger (1998). Corrective feedback was obtained from participants, for example, the summaries were sent to all participants for approval to ensure that our results were valid and members from the research team by critically discussing the findings as recommended by Stalmeijer et al. (2014). 

결과

Results

코칭, 네트워킹, 근무지 조직, 근무지 활동이 교육행위를 촉진/저하 했는가?

How do coaching, networking, organization and activities in the workplace facilitate or impair teaching practice after completion of a faculty development programme? 

(1) 성찰과 피드백의 긍정적 효과 The positive effect of coaching on reflection and feedback. 

(2) 교육 네트워크에 참여 증가 Increased participation in educational networks.  

(3) 조직 정책을 더 인식하게 됨 More awareness of organizational policies.  

(4) 교육 과업과 활동을 하는데 자신감 생김 More confidence in fulfilling educational tasks and activities. 

코칭이 성찰과 피드백을 강화시킴

Coaching enhances reflection and feedback

코치와 함께 교육문제educational question을 논의하는 것이 인사이트의 수준을 높여주었고, 수행능력을 향상시켰다. 코치가 성찰을 자극하고 피드백을 주었기 때문에 teacher는 자신의 교육행위를 더 성찰할 수 있었고, 대안적 전략을 계획할 수 있었으며, 그 결과 능동적으로 새로운 교육행위를 실험해볼 수 있었다. 또한 학습과정에서 피드백의 가치를 더 깨달았다는 언급이 있었다. 교사들은 피드백을 주고 받는 것을 더 많이 했으며, 질적으로로 동료와 학생들로부터 더 훌륭한 피드백을 주고 받았다.

The thematic analysis revealed that the opportunity to discuss educational questions with a coach led to elevated levels of insight and improved performance. As the coach stimulated reflection and provided feedback, teachers reflected more on own teaching practices and planned alternative strategies, and,consequently, experimented actively with new teaching behaviour. What the participants often mentioned was that they gained a better appreciation of the value of feedback in the learning process. Teachers gave and solicited more and qualitatively better feedback to/from both colleagues and students

교육 네트워크에 참여가 늘고, teacher간 자문consultation이 강화됨

Increased participation in educational networking enhances consultation among teachers 

거의 모든 참여자가 교육네트워크가 늘어났음을 보고했다. 즉, 동료들의 교육활동에 대해서 더 많이 자문해주었다. 그렇게 함으로써 UTQ과정에 참여한 동료들에게 연락을 했을 뿐 아니라, 교육에 참여하는 다른 동료들에게도 연락을 하게 되었다. 그러나 이런 과정은 주로 비공식적informal으로 이뤄졌다. 참여자들은 프로그램이 종료된 이후에도 UTQ 멤버들과 접촉이 더 강화intensification되었다고 말하였으나, 반대로 non-UTQ멤버들과의 의사소통은 더 어려워졌음을 느꼈다. 이는 UTQ과정 참여자들은 공통의 교육프레임워크를 공유하기 때문일 수 있다. 일부 과에서는 UTQ구성원들이 qualified teacher의 롤모델 역할을 하며, 다른 동료들의 UTQ참여를 inspire하기도 한다. 일부 UTQ멤버들은 교육에 특화될 계획을 가지고 있으며, MHPE과정을 이수하고 있다.

Nearly, all participants reported an increase in educational networking; that is, they indicated that they consulted colleagues about their teaching activities more frequently. In doing so, they not only called upon colleagues with whom they had participated in the UTQ course, but also on other colleagues involved in teaching. However, this mainly hap-pened on an informal basis. Participants also perceived an intensification of contacts with UTQ members, even after the trajectory had ended, while difficulties in communicating withnon-UTQ colleagues became more apparent. This could be ascribed to the fact that former UTQ-course participants shared a common educational framework. In some departments, UTQ members served as a role model of qualified teachers and inspired others to participate in the UTQ programme as well.Some UTQ members even had plans to specialize in education and to take the master’s in health professions education offered by the FHML. 

조직의 교육정책에 대한 인식이 향상됨

Increased awareness of organizational educational policies

참여자들이 교육커리어를 선호하는 교육문화로 향상된improved것을 경험하였다고 말하였다. 그러나 이것이 모든 과에서 그런 것은 아니었고, 어떤 과에서는 과장이 UTQ참여자들의 교육 전문성을 인정하고 더 자문을 해온 반면, 어떤 과에서는 교육에 별 관심을 보이지 않았다. 동시에, 대부분의 참여자들은 교육조직의 복잡성과 교육정책에 대해서 더 인식하게 되었다. 또한 교육(관련)과 educational department의 역할이 무엇인지 알게 되었으며, 그러한 과에 자문을 더 구하게 되었다. UTQ과정이 참여자들로 하여금 더 많은 교육적 역할을 수행fulfill하게끔 하고, 교육 커리어를 선택하게 한 것도 조직의 문화를 바꾸는 계기가 되었다. 이것이 바로 faculty board에서 UTQ프로그램을 미래의 교육리더들의 발육지breeding ground로 인식하게 된 이유이다. faculty board는 프로그램디렉터의 선정을 맡고 있다. 장애요인으로서 참여자들은 소속 과가 교육에 대한 새로운 인사이트를 수용하지 않는 것을 지적했다. 이렇나 차이 때문에 일부 참여자들은 자신이 예전 행동으로 돌아간다고 걱정했다. 이들 참여자들은 특히 새로이 습득한 행동을 지속하기 위해서 follow-up activities에 의존하였다.

In the focus groups, several favourable and inhibiting condi- tions were discussed. What came to the fore was that partici- pants experienced an improved educational culture within the faculty in favour of educational careers. However, this did not particularly hold for all departments: while some department chairs consulted participants more often for their teaching expertise, other chairs did not show much interest in education. At the same time, most participants reported that they had become more aware of educational policies and the complexity of the educational organization. Moreover, they gained a clearer view of the role of the educational department and more readily turned to the department for advice. The fact that the UTQ course obliged participants to fulfil more educational roles and to opt for an educational career also triggered a change in organizational culture. Hence, it is with reason that the faculty board in a way regards the UTQ programme as a breeding ground for future educational leaders within the faculty. The faculty board is among others, responsible for appointments of qualified programme directors. As regards barriers encoun- tered, participants pointed out that their departments were little receptive to new educational insights. Because of such indif- ference, a few participants feared that they would slide back into old behaviours. These participants in particular resorted to follow-up activities or programmes to hold on to their newly acquired behaviour.

교육적 과제task나 활동을 하는데 자신감이 생김

More confidence in fulfilling educational tasks and activities

근무지에서의 학습을 자극한 동기부여 요인에 대해 언급하였다. 교육과제나 활동에 대해서 인식이 향상되고 분석적 능력이 향상되었다. 교육을 실제로 하거나 교육활동을 계획하는 것도 긍정적으로 변화했는데, 예컨대 불확실성이 줄어든 측면이 있었다. 더 나아가서, 팀 내에서의 협력이 강화되었고, 이는 참여자들이 교육과제나 활동을 진행할 때 동료들로부터 피드백이나 어시스트를  더 쉽게 얻을 수 있었기 때문이다. 마찬가지로 참여자들은 팀-책임이 늘어난 것을 언급했는데, 일부 참여자는 즉각적으로 새롭게 습득한 교육지식을 프로그램의 재설계에 활용했다. 따라서 FD는 personal and professional growth를 촉진했다. 즉, UTQ과정을 이수하지 않은 근무지의 동료들도 그 (교육)지식을 가지고 있는 사람들을 인정해주었다.

The focus groups also addressed several motivational aspects of teacher learning in the workplace. Participants reported more awareness and analytical ability with respect to the educational tasks and activities. Their educational behaviour during delivery of education and planning of educational activities had changed positively, for example in terms of reduced uncertainty. Moreover, collaboration within teams had intensified, as participants for instance more easily solicited feedback or assistance from colleagues about educa- tional tasks and activities. Likewise, participants noted an increase in team responsibilities; some planning groups immediately incorporated the newly acquired educational knowledge into the redesign process of a programme or into an educational approach. Hence, FD facilitates personal and professional growth. In fact, colleagues in the workplace who had not taken the UTQ programme recognized the knowledge of those who had.

고찰과 결론

Discussion and conclusion

전체적으로 코칭과 네트워킹이 커뮤니티 형성의 촉매역할을 한 것으로 보였다. 코칭은 비공식적, 암묵적 학습을 일깨워주었고, 그것이 작동operationalize하게 해주었다. 같은 이유에서, 교수들은 교육조직과 문화에 대해서 더 aware하게 되었다. 이런 효과의 일부는 교육에 대한 더 긍정적인 분위기를 가져왔고, 교육커뮤니티가 birth하였다. 그러나 동시에 과장의 태도에 따라 과 간 상당한 차이가 있었다. 따라서 여전히 큰 장애물이 있으며, Teunissen은 이렇게 말했다.

Through the whole, coaching and networking seemed to function as a catalyst for community formation. Coaching appeared to raise awareness of informal and tacit learning and help to operationalize it. By the same token, faculty became more aware of the educational organization and culture. The sum of these effects invoked an atmosphere that was more favourable to education and gave birth to a community of teaching practice. At the same time, however, significant differences existed between departments due to diverging attitudes adopted by the chairs. Hence, an important hurdle has yet to be taken, a concern that has been deftly voiced by Teunissen (2014) who posited that

"healthcare workplace는 비교적 안정적인 환경으로 변화에 저항하는 경향이 있다. 이것은 개인이 그렇기 때문이라기보다는, 비슷한 사람들이 비슷한 목표를 가지고 비슷한 일을 오래동안 해온 그 행위의 전통 때문이다"

‘‘healthcare workplaces are relatively stable environments that tend to resist change; not necessarily because of individual resistance but because of a practice’s longstanding tradition of having similar groups of people involved in similar tasks with similar goals’’.

Teunissen PW. 2014. Experiences, trajectories, and reifications: Anemerging framework of practice-based learning in healthcare work-places. Adv Health Sci Educ 20:843–856. 

Appendix 

Questions that guided the focus group discussions. 

The goal of the focus group discussions was to investigate the impact of a faculty development programme on teachers’educational workplace environment. Guiding questions were as follows: 

(1) How did formal and informal coaching affect teaching practice after completion of the UTQ programme? 

(2) In what ways did your participation in formal and informal educational networks change?

(3) Which factors facilitated and inhibited teaching practice in the department and the organization? 

(4) How did the UTQ programme affect your tasks and activities in the workplace? 

Communities of teaching practice in the workplace: Evaluation of a faculty development programme.

어떻게 학습이 전이되는가: 어떻게 교수교육펠로우십을 이수한 교수들이 동료와 조직에 영향을 주었는가 (Acad Med, 2015)

How Learning Transfers: A Study of How Graduates of a Faculty Education Fellowship Influenced the Behaviors and Practices of Their Peers and Organizations

Margaret M. Plack, PT, DPT, EdD, Ellen F. Goldman, EdD, Marilyn Wesner, EdD, Nisha Manikoth, EdD, and Yolanda Haywood, MD

프로그램 평가를 근무지의 커뮤니티workplace community까지 확장시키라는 요구는 교수개발에 투자된 재정의 결과일 뿐만 아니라, 행동의 변화라는 것이 맥락-특이적이고 socially experienced 되는 것이라는 인식에 따른 것이다. 기업 연구에서는 학습한 내용의 매우 일부분 (리더십 프로그램에서는 10%)만이 직무수행능력에 적용된다는 것을 보여주기도 했다. 과업관련성, 동료나 상관의 지지 등과 같은 맥락적 요소가 학습 전이를 높이는데 핵심이다.

The call to expand program assessment to the workplace community is the result of the significant funds devoted to faculty development as well as the recognition that changed behaviors (of teaching, scholarship, leadership) are context- specific and socially experienced.4 The business literature indicates that only a small percentage of what is learned in development programs transfers to job performance—as little as 10% for leadership programs, according to one study.9 Further, contextual factors such as task relevance and peer and supervisor support are key to increased learning transfer.9,10

O’Sullivan and Irby는 FDP의 영향력에 영향을 줄 수 있는 근무지커뮤니티의 네 가지 요소를 밝혔다.

O’Sullivan and Irby3 have identified four components of the workplace community that may influence the impact of faculty development programs:

• workplace tasks and activities;

• relationships and networks;

• mentoring and coaching; and

• organizations, systems, and culture.

본 연구는 Master Teacher Leadership Development Program (MTLDP)의 효과에 대한 것

Our study was designed to determine what impact, if any, graduates of the Master Teacher Leadership Development Program (MTLDP), a faculty education fellowship of the George Washington University School of Medicine and Health Sciences (SMHS), had on peers and work units and how that impact occurred.

방법

Method

프로그램 진행기간, 주요 내용

The MTLDP is a yearlong faculty fellowship program aimed at helping faculty enhance their teaching skills, pursue scholarship in education, and develop their leadership potential. The program consists of six graduate courses in adult learning, curriculum design, assessment, qualitative research, teamwork, and leadership. Participants met one-half day per week throughout the year.

시작, 졸업생

Initiated in 2002, the program has graduated 104 medical and health science faculty employed at three different institutions in Washington, DC:

인터뷰

To better understand the impact MTLDP graduates had (if any) on their organization (i.e., Kirkpatrick’s Level 4),4 we used a 60-minute semistructured interview protocol to elicit peer and supervisor perceptions of the graduates’ impact across all program aims: teaching, scholarship, and leadership (Supplemental Digital Appendix 1, http://links.lww.com/ ACADMED/A230). We pilot tested the interview protocol for clarity and audiotaped and transcribed interviews verbatim.

신뢰도 위한 방법

The following served to maximize the credibility and trustworthiness of this study:

• triangulation using multiple researchers and sources of data;

• purposive sampling for diverse perspectives;

• use of rich descriptions to support the emergent themes;

• ongoing search for negative cases;

• member checks; and

• researchers functioning as peer reviewers and devil’s advocates for each other in interpretation and presentation of findings.13

방법을 투명하게 공개함

We made methods transparent to enable readers to judge the credibility and transferability of the findings and conclusions.14,15

결과

Results

불참자: 이유와 특성

Of the 17 supervisors invited to participate, 4 declined, 3 because they were retiring, and 1, recently promoted, did not have time.

Of 32 peers, 7 declined; 4 indicated they did not have direct awareness of the graduates’ educational endeavors, 2 cited lack of time, and 1 wanted to participate but traveled extensively and could not be scheduled.

최종 참가자

In total, 13 supervisors (6 from SMHS; 5 from CNMC; 2 from DC-VAMC) and 25 peers (11 from SMHS; 10 from CNMC; 4 from DC-VAMC) were interviewed. Only two departments at the DC-VAMC had graduates of the program—thus the lower number of participants.

자신감 향상과 행동의 변화

Enhanced confidence and changed behaviors

Supervisors(S) and peers(P)는 MTLDP의 졸업생들이 자신감이 향상되었으며, 이는 교육자/학자/리더로서 모두 그러하다고 했다.

Supervisors and peers alike noted an increased confidence in graduates of the MTLDP, which was evident in their roles as teachers, scholars, and leaders.

S&P는 프로그램의 세 가지 목적인 교육/연구/리더 영역에서 모두 행동의 변화가 관찰되었다고 했다.

Supervisors and peers noted behavior changes across all three program aims (teaching, scholarship, and leadership).

리소스로서의 역할, 전문성의 공유

Becoming resources and sharing expertise within and outside home departments.

졸업생들은 (다른 사람에게) 조언을 주거나, 아이디어 공유, 새로운 테크닉 도입, 새로운 전략 제시, 멘토 역할 등을 했다. 인터뷰이는 졸업생이 교육/연구/리더십에서 새로운 지식과 전문성을 기꺼이 공유하고자 한다고 말했다. 여기에는 레지던트 교육/교육과정 개발/교수 훈련/인증 이슈/혁신적 문제해결 등이 포함된다.

Graduates were described as offering advice, sharing ideas, introducing new techniques, brainstorming new strategies, and providing mentorship. Interviewees affirmed that graduates willingly shared their new knowledge and expertise in pedagogical approaches, research design, and leadership practices. Their comments identified helping with resident education, curriculum development, faculty training, accredita tion issues, innovative problem solving, and more (Table 1).

Best practice과 혁신의 롤모델

Role modeling best practice and innovation.

MTLDP의 졸업생은 성인학습원칙을 도입, 성찰적 실천 촉진, 능동적 학습을 장려 등의 영역에서 모범적 역할을 했다. 졸업생들은 새로운 테크놀로지를 도입했으며, 다른 교수법을 시도해보려고 했고, 지속적인 피드백을 주고, 받고자 했다. scholary activity에서도 주도적으로 역할을 하여, 국내 컨퍼런스에서 정기적으로 발표도 하였다. 팀 미팅에서 의견을 뚜렷하게 제시하고 주도적인 역할을 하여서 자신감이 있지만 calm하였다. 리더로서 이들은 효과적으로 토론을 이끌었고, 미팅의 control을 유지하면서도 모든 사람에게 말할 공간을 열어주었다.

Participants’ comments show that MTLDP graduates led by example as they incorporated adult learning principles, facilitated reflective practice, and encouraged active learning in their classrooms. They leveraged new technologies and were willing to try different pedagogies, and both offered and sought ongoing feedback. They reported taking the lead in scholarly activities and regularly presented at national conferences. In team meetings they described being assertive and directive, yet confident and calm. As leaders, they contributed effectively to discussions and maintained control of meetings while still providing space for all to speak (Table 1).

체계적인 접근법의 롤모델

Role modeling systematic approaches.

어떻게 졸업생들이 새로운 교육과정/프로젝트/혁신의 설계 단계에서부터 평가를 강조했는지에 대한 언급이 있었다. 프로젝트를 기획과 관리, 문제해결에 있어서 methodical 했으며, 졸업생은 근거를 탐색하고, 연구를 수행함에 있어서 rigorous한 기준을 유지하는 것이 확연하였다. 졸업생은 학습자-중심, 성과-중심 의 특성이 있었다.

Interviewees commented on how graduates stressed assessment beginning at the design phase of any new curri- culum, project, or innovation, and viewed assessment as a means of continuous improvement. They reported being methodical in their planning and project management and in their approach to problem solving. Graduates distinguished themselves as being thorough in search ing the evidence and maintaining rigorous standards in conducting research. They described being learner centered and outcome focused (Table 1).

협력을 촉진

Fostering collaboration.

졸업생들이 여러 disciplines에 걸쳐서 일하는 것을 편안해한다고 했다. 상호작용을 장려했으며, 팀에서 shared meaning을 만드는 것을 강조했다. 교육자료를 기꺼이 공유하고자 했고, 동료들로 하여금 scholarly pursuit에 함께하자고 했고, 동료들에게 멘토가 되었고, scholarly presentation을 했고, collaborative work group의 강력한지지자였다.

Participants noted that graduates regularly felt comfortable working across disciplines. They described encouraging interactions and the development of shared meaning on teams. Participants’ comments affirm that they willingly shared teaching mate- rial, inspired peers to join in scholarly pursuits, mentored fellows, offered scholarly presentations, and were strong advocates for collaborative work groups (Table 1).

지속적학습의 문화culture of continuous learning를 촉진

Facilitating a culture of continuous learning

critical mass가 만들어졌으며, 졸업생들은 교육리더십 기회를 받아들였고, culture of continuous learning이 생겨났다.

Comments revealed that as a critical mass developed and graduates accepted educational leadership opportunities, a culture of continuous learning began to develop across the organization as illustrated by the following comments:

토론

Discussion

O’Sullivan and Irby의 모델에 '어떻게 work group에 학습이 전이되는가'에 대한 내용이 더해졌다. 졸업생의 critical mass가 형성되고, 리더십의 기회를 제공하는 것이 학습의 전이를 촉진하고 지속적학습의 문화를 장려하는데 기여한다.

We believe this adds a dimension to O’Sullivan and Irby’s model,3 as reconceptualized in Figure 2, that describes how learning transfers to the work group. Further, having a critical mass of graduates and providing oppor- tunities for leadership facilitated that lear ning transfer and fostered a culture of continuous learning within the work group.

연구 결과는 학습이 social process라고 보는 workplace learning에 대한 기존 연구와 부합한다. 한 사람이 배운 내용을 다른 곳(workplace)에 전이하는 것은 협력, 직무활동에 함께 참여, 정보 교환, 지도guidance 받기, 코치 받기, 행동의 관찰과 모밤을 통해서 가능하다.

Our findings are consistent with the workplace learning literature, which describes learning as a social process.16 Transferring what one person learns to another in the workplace occurs through

• collaboration and participating in work activities together,

• exchanging information,

• receiving guidance,

• being coached, and

• observing and copying behaviors.17,18

근무지학습 문헌을 보면, transfer는 비공식적으로 발생하는 것이며, 멘토링이나 과제완수, 미팅참석의 부산물로서 우연히 발생한다. 우리의 연구 결과는 transfer의 상당부분은 우연히, 그리고 work group units across the organization에서 발생하며, 이것이 의미하는 바는 더 큰 조직구조 수준에서 이것이 learning으로 인정되고 있지 않고, 따라서 프로그램의 가치를 인정받는데 한계가 된다. 종합적으로, 우리의 연구결과는 FDP가 조직에 미치는 영향에 대해서 말하고 있으며, Kirkpatrick의 4레벨은 평가가능하고 실제로 발생한다.

The workplace learning literature describes the transfer as taking place informally,19 through both deliberate means such as mentoring, and incidentally as a by-product of task completion and meeting attendance. Our findings suggest that a significant portion of the transfer takes place incidentally and within work group units across the organization, which may mean that it is not acknowledged as learning within the larger organizational structure, thus limiting the recognition of the program’s value.20,21 Overall, our analysis indicates that the impact of a faculty development program on the organization—for instance, Level 4 as described by Kirkpatrick4—can be assessed and does occur.

Critical mass와 Educational leadership opportunities가 핵심 요인이다. 다음과 같은 상황에서는 전이가 발생하지 않는다.

Our interviewees identified critical mass and educational leadership opportunities as key factors aiding transfer. In another health care context, transfer of training was found to be absent because of

• 조직의 서포트가 분절됨 fragmented organizational support,

• 적용할 시간이 없음 lack of time to practice what was learned, and

• 조직의 전략과 잘 맞지 않음 lack of alignment with organizational strategy.22

MTLDP의 졸업생은 기회가 있었고, 그렇게 하는 것이 장려되었으며, 조직의 전반적 지향과 맞았다.

The graduates of the MTLDP had opportunity to apply what they learned pre- and post graduation, and were encouraged to do so, and the program aims are consistent with each of the three organization’s overall direction of building teaching, scholarship, and leadership excellence. Although these additional factors were not explicitly stated in our findings, they may be equally important to learning transfer.

7 Lown BA, Newman LR, Hatem CJ. The personal and professional impact of a fellowship in medical education. Acad Med. 2009;84:1089–1097.

10 Yamnill S, McLean GN. Theories supporting transfer of training. Hum Res Dev Q. 2001;12:195–208.

How learning transfers: a study of how graduates of a faculty education fellowship influenced the behaviors andpractices of their peers and organizations.

의학교육에서 교수개발의 발전: A Systematic Review (Acad Med, 2013)

Advancing Faculty Development in Medical Education: A Systematic Review

Karen Leslie, MD, MEd, Lindsay Baker, MEd, Eileen Egan-Lee, MEd, Martina Esdaile, MA,

and Scott Reeves, PhD, MSc

지난 수십년에 걸쳐서, 교수에게 "창의적이고 효과적인 teacher, 성공적인 researcher, 생산성 높은 clinician"이 될 것을 요구하는 광범위한 변화들이 있어왔다.

Throughout the last few decades, extensive changes have resulted in increasing demands on faculty to be “creative and effective teachers, successful researchers, and productive clinicians.”2

Stritter는 FD를 교수들의 교육수행능력 향상을 위한 전략strategies to improve faculty members’ teaching performance이라고 개념화했다. 이후 리뷰에서는 교수의 확장된 역할(행정가, 스칼라십, 리더십)을 포함한 더 포괄적인 FD의 정의가 요구되었다. 그러나 캐나다의 FD변화에 대해서 추적한 지난 30년간 진행된 일련의 설문을 보면, 비록 그러한 프로그램이 교수들의 요구를 충족시키기 위하여 시작되었지만, 여전히 주로 교육수행능력 향상에 초점을 두고 있다.

Stritter4 initially conceptualized FD as strategies to improve faculty members’ teaching performance. Subsequent reviews5,6 have called for a broader definition of FD, based on the expanding scope of faculty roles, including administration, scholarship, and leadership. However, a series of surveys1,7,8 conducted over the past 30 years, which described and tracked changes in FD programs in Canadian medical schools, indicate that although such programs have begun to address the breadth of faculty members’ needs, their focus remains on strategies to improve teaching performance.

목적

Our specific objectives were threefold:

(1) to provide an account of the nature and scope of FD programs,

(2) to provide an assessment of the quality of FD studies, and

(3) to identify in what areas and through what means future research can purposefully build on existing knowledge.

방법

Method

연구포함기준

Eligibility criteria

We included articles that reported program evaluations of FD initiatives for both basic science and clinical faculty in academic medicine.

We included only peer-reviewed articles published between January 1989 and December 2010.

We excluded articles that had been included in previous FD reviews (e.g., by Steinert and colleagues12) to avoid repetition and to build on their findings.

연구문헌 탐색과 선택

Search strategies and selection methods

We used two approaches to locate articles for inclusion in our review. First, we searched for relevant articles published in the past 21 years (January 1989 to December 2010) using the electronic databases MEDLINE, CINAHL, and ERIC. We chose these three databases because they span the health professions.

Second, we conducted manual searches of three leading medical education journals that publish articles on FD initiatives (Academic Medicine, Medical Education, and Medical Teacher) for the same period (January 1989 to December 2010).

데이터 추상화, 분석, 종합

Data abstraction, analysis, and synthesis

Building on Barr and colleagues’15 and Steinert and colleagues’12 use of the Kirkpatrick model, we further modified our list of outcomes to the following seven categories:

(1) learner reaction (level 1),

(2) modification of attitudes/perceptions (level 2a),

(3) acquisition of knowledge/skills (level 2b),

(4) behavioral change (level 3),

(5) changes in organizational practice (level 4a),

(6) benefits to students/residents (level 4b), and

(7) benefits to patients/ communities (level 4c).

질 평가

Assessing the quality

두 가지 차원에 대해서 5점척도로 평가: 연구 자체의 퀄리티, 연구에서 도출한 결과의 퀄리티

We calculated scores (out of five points) along two dimensions—the quality of the study and the quality of the information provided in the article.16 Only articles that attained at least three points on both dimensions were eligible for inclusion in our review.

결과

Results

프로그램의 목표

Many of the included studies had multiple aims.

• The most common program aim was to improve teaching effectiveness; 15 of the 21 programs included this goal as one of their primary objectives.17–20,23–27,30–33,35–37

• The second most common program aim (n = 8) was scholarship,21,23–25,28,33,34,37 which encompassed such activities as curriculum design and the development of research skills.

• Four programs had the development of faculty developers as an objective22,28,29,38; that is, participants attended the initiative to become faculty developers themselves and to implement FD initiatives at their home institutions.

• In addition, 4 programs described career development as an objective20,23–25; they aimed to nurture participants’ professional effectiveness, professional academic skills, career management, and administration skills.

• Finally, 3 programs noted leadership as an aim,24,28,29 including enhancing participants’ ability to understand and influence change in their local setting, gaining leadership skills, and creating leadership focused on changing culture.

평가 접근법

Evaluation approaches

연구방법

Table 1 provides a summary of the evaluation designs, data collection methods, and data analysis approaches employed by the studies in our review. Although 8 of the studies reported the use of mixed methods19,25,26,28,30,34,37,38 and 2 studies employed qualitative methods only,29,36 the focus remained predominantly on quantitative approaches, with 12 studies employing only quantitative methods.17,18,20–24,27,31–33,35 Only 4 studies mentioned a theoretical or conceptual framework for the evaluation design.24,25,33,37

연구설계

A number of studies employed longitudinal designs—6 with more than three data collection points over time.22,24,27,29,32,34 Fifteen studies included some follow-up component, ranging from 2 months to 13 years post intervention. In addition, 9 studies included a control or comparison group in their design.17,19–21,23,26,27,32,35

자료수집방법

Although 9 studies used more than one method of data collection, 13 studies relied on only one data collection method. Not surprisingly, surveys were the most popular method to collect data (n = 18).17,19–24,27–35,37,38 These ranged from complex research instruments to “happy sheets,” which gathered participants’ immediate reactions to the program. Six of these studies used a previously validated instrument. In addition, 3 evaluations analyzed data from interviews25,36,37 and focus groups,37 which were recorded and transcribed, 3 collected observational data,26,34,38 and 3 analyzed the curriculum vitae of participants.24,25,34 Other methods described included analyzing teaching scores, student marks, and progress reports.

자료원의 숫자

Half of the studies used more than one data source (n = 11).17,19–21,23,26,29,32,34,35,38 In general, participants were the most common source of data (n = 21). However, at times, data collected from participants were augmented by data gathered from comparison groups (n = 8), students (n = 6), and facilitators (n = 2).

결과 보고

Reported outcomes

1. 반응

Level 1: reaction.

Nine studies assessed outcomes at this level, which included participants’ satisfaction, perception of program usefulness and acceptability, and value of the activity.20,24,28,30,32–34,37,38 Participants’ reactions were usually measured with a survey immediately following the program.

2a. 태도/인식

Level 2a: attitudes/perceptions.

Fourteen studies addressed participants’ attitudes, which included motivation, self-confidence, enthusiasm, and conceptions of teaching and learning.17,19–21,23,25,26,28,30–33,36,37 This outcome was largely self-reported (n = 12); however, students and residents observed and reported shifts in faculty member participants’ attitudes in 2 studies.26,32 This outcome also was most often measured using surveys (n = 9).17,20,21,23,28,30–33 In addition, 6 of these studies recruited a comparison group of faculty to either fill out the survey themselves or to have their students/residents complete it with them in mind. Finally, in 3 studies, interviews were used to collect data about participants’ attitudes.25,36,37

2b. 지식/스킬

Level 2b: knowledge/skills.

Sixteen studies evaluated outcomes related to participants’ knowledge and skills.19–21,24–33,35–37 Although self-reported data were most common (n = 12), 5 studies presented data related to participants’ knowledge and skills as observed by others (e.g., expert medical educators). Surveys were the most common data collection method, used in 11 of the 16 studies.20,21,23–35 In addition, interviews were employed in 3 studies.25,36,37

3. 행동

Level 3: behavior.

By far, the most commonly reported outcome was participants’ behavior change, measured in 21 of the 22 studies.17–19,21–38 Behaviors measured included delivery of workshops, educational practices and teaching skills, and research productivity. Fourteen studies presented self- reported behavior outcomes, whereas 7 reported participants’ behaviors as observed by others (e.g., students). Two studies included both self-reported and non-self-reported outcomes.19,29

다양한 자료수집방법이 활용됨

In comparison with the other reported outcomes, a variety of methods were used to gather data about participants’ behavior change, including surveys (n = 16)17,19,21–23,27–35,37,38 and interviews with participants (n = 3),25,36,37 the collection of observational and video data (n = 2),18,26 the analysis of curriculum vitae to track career achievements (n = 3),24,25,34 and the analysis of narratives written by participants to illustrate the influences of the FD process on their behavior (n = 1).19

4a. 조직 행동

Level 4a: organizational practice.

These outcomes measured changes that affected the organization in some way, such as the development of new programs or new curricula; the retention of faculty; new hires; and culture changes. Organizational changes were reported in 9 studies19,22,24,26,28,29,31,33,38 and were mostly captured by self-reported follow-up surveys (up to 24 months after participation in the FD initiative) and progress reports submitted by participants.

4b. 학생의 이득

Level 4b: student benefit.

Three studies assessed the benefits to students of FD programs.19,27,29 All three reported the results of surveys completed by individuals other than the FD program participants.

4c. 환자의 이득

Level 4c: patient benefit.

Two studies included the self-reported benefits to patients.31,37 Participants completed surveys about how the changes they made in their clinical practices as a result of the FD program affected the quality of their patient care.

고찰

Discussion

Steinert등, Sambunjak 등의 연구결과와 비교하면 최근들어 FD이니셔티브의 범위scope나 평가방법이 확장됨을 알 수 있었다. 예컨대, 본 연구에서는 FD프로그램이 교육스행능력에만 초점을 두던 것에서 벗어나서 다양한 목적을 가지기 시작했으며, 한 프로그램 내에서도 그러했다. 프로그램은 점점 스칼라십/리더십/교수개발요구 등을 지원하고 있었다. 이러한 변화는 변화하는 의학교육와 의료시스템의 환경에 따라 교수들의 요구가 진화한 것에 대한 반응으로 보여진다. 흥미롭게도, 교수개발자들의 개발은 여러 프로그램의 목표였으며, 어떻게 build capacity를 할 것인가에 대한 지식을 확장시키고자 하는 요구addressing the need to extend knowledge about how best to build capacity라고 할 수 있다.

Our review found some expansion in both the scope of FD initiatives in recent years and the evaluation methods employed by researchers, compared with the findings of Steinert and colleagues12 and Sambunjak and colleagues.11 For example, our findings suggest that FD programs are beginning to move away from a focus on teaching performance alone toward a variety of objectives, often within the same program. Programs are increasingly aiming to assist faculty with their scholarship, leadership, and career development needs, in addition to their teaching skills. This shift may mirror the evolving needs of faculty in response to the changing landscape of medical education and the health care system.2,3 Interestingly, the development of faculty developers was an aim in several of the programs, addressing the need to extend knowledge about how best to build capacity.

연구자들은 자료수집 시에 한 가지 방법에만 의존하는 경우가 많다. 인터뷰/관찰/CV분석 등을 활용하기도 했지만, 가장 흔한 것은 unvalidated survey였다. 유사하게, 두 개 이상의 자료출처를 사용하는 경우가 늘어나고는 있지만, 프로그램 참가자가 가장 주된 자료출처이다. 자기보고자료에 의존하는 것이 FD문헌의 common thread였다.

Our findings also illustrate that researchers continue to rely on a single method of data collection (see Appendix 1). Although some studies used interviews, observations, and curriculum vitae analysis, the most common form of data collection was the use of unvalidated surveys. Similarly, despite an increasing number of studies employing more than one data source (including students and FD program facilitators), program participants remained the predominant source of data. This reliance on self- reported data is a common thread in the FD literature over the years.12

마지막으로, 흔히 사용되는 성과척도는 다음과 같은 것들이 있다. 반응reaction에 의존하던 모습이 변한 것은 긍정적이지만, 교육 프로세스나 맥락적 요인의 상호작용interplay는 비교적 관심을 받지 못하였다 O'Sullivan과 Irby는 전통적인 FD연구의 선형모델에서 벗어나야 한다고 했다.

Finally, our findings indicate that the most common outcomes measured included participants’ self-reported behavior changes, acquisition of knowledge and skills, and changes in attitudes and perceptions (see Appendix 1). Although this shift from relying on reaction outcomes is a welcome change, little focus has been placed on the educational process or the interplay of contextual factors that affect the success of FD. Perhaps, as O’Sullivan and Irby40 suggest, it is time to move away from the traditional linear model of FD research that focuses on the individual participant. They offer instead a new model that is more cyclical in nature and that focuses on the interaction between the FD community and the workplace community.

우리의 연구 결과에 근거해서 다음을 권곻ㄴ다.

On the basis of our findings, we propose the following recommendations for future FD research

• 양정, 질적 방법
   First, researchers must continue the trend toward more rigorous approaches to program evaluation. The growing use of mixed methods should be encouraged because such approaches provide for comprehensive and robust studies that produce rich data. Combining both qualitative and quantitative perspectives allows researchers to generate findings that focus on both the teaching processes and the outcomes of those processes.

• 이론프레임워크
  Related to this trend is the need for the use of theoretical frameworks in designing evaluation studies. Grounding such studies in the broader literature is necessary if FD scholarship is to engage in dialogue and align with the health professions education research community as a whole.

• 참가자 말고도 퍼실리테이터의 역할 등에 대해서도. 전문직간 팀, 실천공동체, 어떻게 행동변화가 일어나는가 등
  Second, researchers must expand beyond studying solely participants’ outcomes; they also must include multiple sources of data. For example, only a small percentage of the studies included in our review employed facilitators as data sources, and those that did usually used them to provide their perceptions of the changes in participants rather than to share their own experiences. Others support our call to explore further the role that facilitators can play in measuring the success of FD programs.40,41 Similarly, FD research currently overlooks the role of interprofessional teams and communities of practice in the workplace. Furthering this line of research would put us a step closer to understanding how behavior change occurs within the practice environment.

• 다기관 연구
  Finally, the bulk of FD evaluations are completed at a single institution, which limits the inferences one can draw from such studies. More multisite studies are needed to produce more compelling empirical research. Multisite studies also would explore the complex ways in which different organizational and contextual factors shape the success of FD programs.

Acad Med. 2013 Jul;88(7):1038-45. doi: 10.1097/ACM.0b013e318294fd29.

Advancing faculty development in medical education: a systematic review.

스니펫: 효율적, 효과적 교수개발의 혁신적 방법 (J Grad Med Educ. 2014)

Snippets: An Innovative Method for Efficient, Effective Faculty Development

Miriam E. Bar-on, MD

Lyuba Konopasek, MD

교수개발의 주요 장애요인

This has been identified as the primary barrier for faculty attendance at faculty development sessions.5–11 Other barriers to partic- ipating in faculty development include

• 리소스 resources;

• 상충하는 우선순위 compet- ing priorities, such as patient care, research, and adminis- trative tasks; and

• 교육에 대한 낮은 경제적 보상과 인정 the lack of financial rewards or social recognition for the teaching role.5–11

또 다른 장애요인

Perhaps, the most significant psychologic barrier to participation in faculty development is

• 교육보다 연구나 진료를 더 가치있게 여기는 기관
  the real or perceived lack of institutional support for teaching, with institutions frequently appearing to place a higher value on clinical and research-related activities than they do on teaching.2,5,6,10,11

스니펫

The Snippet

스니펫은 보통 20분 이내의 짧은 시간내에 이뤄진다. 아주 드물게 30분까지 늘어날 수도 있다. 스니펫은 single overriding communication objective (SOCO)에 초점을 둔다. 스니펫을 설계할 때는 반드시 SOCO를 신중히 골라야 하는데, 이 SOCO는 할당된 시간 내에 교육할 수 있어야 하고, 그 세션에 참가한 역할이나 직무와 관계가 있어야 한다.

Snippets are short, generally limited to 20 minutes. In rare instances, they may extend to 30 minutes. The focus of a snippet is a single overriding communication objective (SOCO).19 The de- signer of the snippet must carefully select a SOCO—a topic or skill—that can be taught in the allotted time, and is relevant to the role and work of the individuals who will attend the session.

스니펫은 고도로 구조화되어 있다. 스니펫은 최대 10개 슬라이드까지 허용되며, 왜냐하면 대부분 교수개발을 진행할 때 슬라이드 말고도 다른 media를 활용하기 때문이다. 10개 슬라이드 중 3개는 타이틀, 학습목표, Take-home point이다. 추가적으로, 핵심학습요점을 정리한 슬라이드가 포함되며, 새로운 지식이나 스킬을 활용하는 상호작용적 실습을 위한 슬라이드가 있어야 한다. 교육하는 내용이 근거에 기반한 것이라는 것을 보여주기 위하여 관련된 문헌을 인용해야 한다.

Snippets are highly structured. They include a maxi- mum of 10 slides because most individuals giving faculty development sessions employ slides and other media. Of the 10 slides, 3 include the title slide, learning objectives, and take-home points. In addition, slides must be allocated to the key learning points of the topic and to a possible interactive exercise to allow application of the new knowledge or skill (BOX1). Citations from the education literature should be included to demonstrate that the approach taught is based on evidence.

스니펫 개발

Snippet Development

스니펫을 만들 때는 기본적으로 네 단계가 있다.

To develop a snippet, there are 4 basic steps (BOX2).

• 첫 번째 스텝은 가르칠 주제나 스킬을 정하고, 근거-기반을 마련하기 위하여 문헌을 고찰하는 것이다.
  The first step entails selecting an educational topic or skill to present and a review of the literature to create the evidence base.

• 이 과정이 완료되면, 교육할 핵심 요점을 결정한다. 이 단계의 한 부분으로서, 스니펫 개발자는 한 차례의 스니펫이 모든 내용을 다 담을 것인지, 시리즈로 여러 스니펫에 나눌 것인지 결정해야 한다.
  Once that is completed, the second step is to determine the key points that will be presented. As part of this step, the developer must determine whether to present the whole topic or skill as 1 snippet or as several snippets in a series.

• 스텝 3은 교육하려는 토픽이나 스킬을 시범보일 수 있는 (실습)활동을 선정하는 것이다. 여기에는 사례조사, 역할극, 차트리뷰, Critique와 함께 시험보이기, 비디오 시청, 게임 등이 있다. 활동을 선택할 때 학습을 최대화하는 방법인지 고려해야 하고, Debrief의 유형을 계획하고, 활동 이후에 토론을 포함해야 한다.
  Step 3 is to select an activity to demonstrate the educational topic or skill. Such activities may include, among others, case study, role play, chart review, a demonstration of teaching a procedure with critique, watching a video or movie clip, or playing a game. In selecting the activity, it is important to consider the type of instructions to provide participants to maximize the learning and to plan the type of debrief and/or discussion to have following the activity.

• 마지막 단계는 take-home point를 넣는 것
  The final step—step 4—entails formulating take-home points and ensuring participants have the opportunity to hear them.

스니펫 발표를 위한 타이밍을 잡는 것이 매우 중요한데, 왜냐하면 스니펫은 특정 주제에 대해서 한정된 시간 동안 이뤄지기 때문이다. 스니펫이 너무 길어지면, 미래에 스니펫을 위한 시간이 할당될 가능성이 낮으며, 발표자가 신뢰도가 낮아 보일 수 있다. 스니펫이 너무 짧아져버리면 핵심 학습요점을 놓칠 수 있다. 스니펫은 fine-tune timing을 위하여 리허설을 히야 하고, interactive acitivties를 하는 중에 시간에 유의해야 한다.

It is especially important to work out the timing for snippet presentations because snippets are allocated a specific amount of time on an agenda. A snippet that goes too long may make it less likely that time is allocated for this activity in the future and may also make the presenter look less credible. If the presentation is cut short, key learning points may be missed. Snippet presenters must rehearse their talks to fine-tune timing, and they must keep a close eye on time during interactive activities.

20분 모듈보다 더 길어질 것 같은 토픽은 더 작은 단위로 쪼개지거나, 더 extensive한 FDP를 위한 '예고편'으로 사용할 수 있다.

There are many topics (BOX3) that can be—and have been—developed into a snippet format. Topics that are more complex than a 20-minute module can be broken down into smaller bites or can serve as an ‘‘appetizer’’ for a more extensive faculty development session.

고찰

Discussion

스니펫은 각 교실의 FD요구를 지원하고, 인증요건을 만족시키기 위하여 2007년 the University of Nevada School of Medicine 에서 만들어졌다. 스니펫 기본 세트가 만들어진 이후, 매달 진행되는 교수미팅에서 활용되었다.

Snippets were initially developed at the University of Nevada School of Medicine in 2007 to meet departmental faculty development needs and accreditation requirements. After a basic set of snippets were developed, they were incorporated into monthly faculty meetings across all departments that sponsored residency programs.

참가자 반응은 긍정적

Feedback from attendees at these workshops was strongly positive and indicated that many participants planned to implement the snippets concept in their home institutions.

교수개발에 스니펫 모델을 도입한 일부 사례들

Faculty members who participated in the workshops have incorporated the snippet model into their institutions. Here are a few examples of institutions that have adapted the snippet model of faculty development:

• At the University of South Alabama, Department of & Pediatrics, the student clerkship director attended a workshop at the Council of Medical Student Educators in Pediatrics (COMSEP) and has integrated snippet faculty development sessions into his departmental faculty meetings in collaboration with the pediatrics program director. Two lead medical educators in the Department of Pediatrics performed a combined needs assessment of the faculty to help focus and build the topics for their snippet series. Using that information, they developed monthly sessions lasting approximately 15 minutes to provide teaching tips and basic skills for members of the department. In addition, by working with the Office of Continuing Medical Education (CME), they have been able to give 0.25 hours of CME category 1 credit to attendees. In 2012, the snippets program was extended to their faculty advisor committee, and 0.5 hours of CME category 1 credit was provided. Beginning with the 2013–2014 academic year, members of the University of South Alabama, Department of Pediatrics, required the Clinical Competency Committee to participate in snippets, and the members receive CME credit for their participation. Further, both that individual and the program director participated in delivering the workshop at a combined COMSEP/APPD meeting in April 2013.

• Use of snippets at the Icahn School of Medicine at & Mount Sinai followed a less formal model. An attendee from the ACGME Annual Educational Conference stated, ‘‘I have used it several times—I don’t always follow the format exactly, but I have ended a handful of meetings with a 10-minute teaching component and try to keep it interactive and focused on what behaviors/skills they will incorporate.’’

• At the George Washington University School of & Medicine and Health Sciences, Department of Pediatrics, a workshop was presented by 2 individuals who attended the snippets workshop at the combined COMSEP/APPDmeeting. This group also planned an education grand rounds in September 2013, which was delivered in the snippet format.

요약하자면, 스니펫은 매우 구조화된, 바쁜 교수들을 위한 짧은 교수개발의 "단편bites"이다. 전통적인 FDP를 대체하지는 못하나, 그것을 보충하는 역할을 할 수 있다. 스니펫은 교수들이 (교수개발 목적이 아닌) 다른 필수 세션을 참석하는 시간을 활용하여 인증요건을 충족시킬 수 있다. CME사무실에 제출하여 평점을 받을 수 있으며, 이것이 루틴한 교수 미팅에 가치를 더해준다. 마지막으로 온라인 스니펫 저장소를 만드는 것은 스니펫 개발에 참여할 인센티브일 뿐만 아니라 best practice in FD를 위한 site가 된다.

In summary, snippets are well-structured, short ‘‘bites’’ of faculty development for busy faculty educators. They do not replace traditional faculty development but supplement it with an efficient method to deliver information and skills in brief sessions that are sensitive to the identified key constraints in faculty development. Snippets meet accred- itation requirements by engaging a department’s teaching faculty when the faculty is attending another required session. Snippets can be submitted to CME offices for incremental credit, which provides value-added material to routine faculty meetings or other meetings with required attendance. Finally, the development of an online reposi- tory of snippets can serve not only as incentive to participate in snippet creation but also as a site for best practices in faculty development.

3 Clay MA II, Sikon AL, Lypson ML, Gomez A, Kennedy-Malone L, Bussey-Jones J, et al. Teaching while learning while practicing: reframing faculty development for the patient-centered medical home. Acad Med. 2013;88(9):1215–1219.

4 Cook DA, Steinert Y. Online learning for faculty development: a review of the literature. Med Teach. 2013;35(11):930–937.

19 Centers for Disease Control and Prevention. Single overriding communication objective (SOCO) worksheet. March 2013. http://www.cdc. gov/healthywater/emergency/dwa-comm-toolbox/tools-templates-main. html. Accessed August 30, 2013.

J Grad Med Educ. 2014 Jun;6(2):207-10. doi: 10.4300/JGME-D-13-00362.1.

Snippets: an innovative method for efficient, effective faculty development.

본다, 한다, 그리고는? PGME에서의 교수개발(Postgrad Med J. 2008)

See one, do one, then what? Faculty development in postgraduate medical education

T Swanwick

과거에는 누구나 가르칠 수 있다고 생각했지만, 정말로 가르친다는 것이 우연에 맡겨도 되는 것인가? PGME는 변하고 있다. 의학교육의 전문화와 교육의 수월성을 추구하는 원동력이 임상교사의 높아져가는 책무성과 합해져서 stakes를 높이고 있다. 'Teaching the teachers' 혹은 교수개발은 더 이상 사치품이 아니며, 중요한 성과를 위한 핵심 활동이다.

In the past it was assumed that anyone could teach, but is this really something that should be left to chance? Postgraduate medical education is changing. A move to professionalise medical education and a drive for excellence in education, coupled with an increasing accountability of clinical teachers, is raising the stakes. ‘‘Teaching the teachers’’, or faculty development, is no longer an added luxury, but a core activity with impor- tant consequences.

교수개발은 무엇이며 왜 중요한가?

WHAT IS FACULTY DEVELOPMENT AND WHY IS IT IMPORTANT?

Steinert는 이렇게 말했다.

Steinert1 describes faculty development as:

‘‘…a planned program, or set of programs, designed to prepare institutions and faculty members for their various roles, with the goal of improving instructor’s knowledge and skills in the areas of teaching, research and adminis- tration’’

교수개발은 단순히 "가르치는 사람들에게 가르치는 방법을 가르치는 것'이 아니다. 이것은 clinical teacher의 교육활동을 전문화하기 위하여, 교육 인프라를 강화하기 위하여, 미래의 교육역량을 축적하기 위하여 추구하는 전 기관 차원의 활동이며, 다른 말로 하면 trainer와 trainee가 하는 일의 한중간에서 education clinician을 만드는 것이다. 교수개발이 "계획된 프로그램"이라는 측면이 특히 중요한데, 교수개발이 novice clinical teacher에게 입문 수준의 훈련을 제공하는 것 뿐만 아니라, 지속적인 ongoing professional development 의 기회가 되어야 한다.

Faculty development is more that just about ‘‘teaching the teachers to teach’’. It should be an institution-wide pursuit with the intent of profes- sionalising the educational activities of clinical teachers, enhancing educational infrastructure, and building educational capacity for the future—in other words, establishing education clinician and training at the centre of what trainers, and trainees, do. The ‘‘planned program’’ aspect of faculty development is particularly important, as not only should faculty development provide entry level training for novice clinical teachers, there must also be opportunities of ongoing professional development and support.

잘 훈련받은 의사가 더 환자진료를 잘 할 것이라는 것에는 핵심 가정이 있다.

 the belief that well trained doctors carry outbetter patient care holds a number of key assumptions, namely that: 

• 학습을 촉진하는 더 좋은/덜 좋은 방법이 존재한다. there are some good—and less good—ways to facilitate learning 

• 트레이너를 훈련시키는 것은 Trainee outcome을 향상시킬 것이다. training the trainers results in better trainee outcomes 

• 인적자원에 투자하는 것은 조직성과를 향상시킬 것이다. investing in human capital enhances organisa- tional outputs.

세 가지 형태의 교육이 의학교육을 지배해왔다. "연단의 현자", "대가 주위 배회", "핀잔주는 교육". 이 모두는 문제가 있다. 전통적인 강의 형식은 이미 40년 전부터 지식의 전이에 있어서 유용하지 못한 것poor vehicle으로 알려져 왔으며, 강의의 요점 중 42%만이 강의 직후에 기억나며, 이는 1주일 이내에는 20%, 이후에는 3~5%까지 낮아진다. 이 숫자에도 불구하고 PGME에서 강의는 여전히 주로 사용되는 방법이다.

Three forms of teaching have historically held sway in medical education: ‘‘the sage on the stage’’, ‘‘hanging around with the big boys’’ (also known as ‘‘learning by lurking’’), and ‘‘teaching by humiliation’’. All have their problems. The tradi- tional lecture format has been known for over 40 years to be a poor vehicle for the transfer of knowledge2 with only 42% of the key point of a lecture being recalled immediately afterwards, dropping to 20% within a week and to 3–5% thereafter. Despite these depressing figures, the lecture continues to be the staple diet of post- graduate education centres.

더 훌륭하고 나은 의사의 옆을 맴도는 것 만으로도 효과적인 학습이 가능할 수도 있으나, 이는 trainee가 (진료에) 기여하고 참여할 기회가 있을 때의 이야기이다. 시니어의 활동에 함께 할 수 있는 허가가 없이는 trainee는 수동적 관찰자의 역할 밖에 할 수 없으며, 학습경험이란 존재하지 않는다.

Simply being around bigger and better doctors may well be an effective way to learn, but only if the trainee is provided with opportunities to contribute and participate.3 Without permis- sion to join in with the activities of seniors, the trainee is confined to the role of passive spectator, and the learning experience is impoverished.

마지막으로, '핀잔주는 교육'은 - 회진에서 trainee를 박살내는 흔한 모습으로 - 비록 점차 사라질 것으로 기대되지만, professional development를 위한 자신감을 약화시키는 것으로 나타난 바 있다.

Finally, teaching by humiliation—the ritualistic dismantling of trainees on the ward round—though hopefully on the wane, has been shown to undermine the self confidence needed for the professional development of trainees and students.45

Senge는 다음과 같은 'learning organization'은 유연하고/적응력이 있으며/생산성이 높다고 하였다.

Senge has argued that learning organisations:

‘‘… where people continually expand their capacity to create the results they truly desire, where new and expansive patterns of thinking are nurtured, where collective aspiration is set free, and where people are continually learning to see the whole together’’13

are flexible, adaptive and productive.

왜 지금인가?

WHY NOW?

의학교육의 전문화

Professionalisation of medical education

영국에서는, 어느 정도는 Dearing report의 권고안 때문이나, 의과대학에 속한 의학교육학교실의 숫자가 늘어나고 있으며, 석사과정 프로그램과 postgraduate certificates가 늘어나고 있다.

In the UK, driven in part by recommendations of the Dearing report on the future of higher education15 (box 1), there has been a growth in the number of departments of medical education attached to medical schools, and a proliferation of masters level programmes and postgraduate certificates,16

(의학교육의) 책무성 증대

Increasing accountability

의학교육에서 이 책임은 다양한 방향에서 들어온다.

In medical education, this accountability is felt in a number of directions;

• 환자로부터 to the patient, through government agendas around ‘‘patient choice’’ and ‘‘patient safety’’;

• 피훈련자로부터 to the trainee as witnessed by the increasing importance laid on student evaluations, particularly in the USA, through to a growing number of appeals and legal challenges; and

• 규제기구로부터 to regulatory bodies, a role taken in the UK by the Postgraduate Medical Education and Training Board (PMETB).

수월성의 추구

Pursuit of ‘‘excellence’’

'수월성', '세계수준'과 같은 용어는 오늘날 영국에서 정치적 유행어political buzzwords이다.

‘‘Excellence’’ and ‘‘world classness’’ are the current political buzzwords in the UK public sector, cascading from the prime minister down.

어떤 유형의 교수개발?

WHAT SORT OF FACULTY DEVELOPMENT?

전형적인 내용

A typical content list is provided in box 2.24

교수개발 프로그램에 대한 최근의 systematic review에서는 교수개발 프로그램의 효과성에 기여하는 요인으로..

A recent systematic review looking at effectiveness of faculty programmes28 development found that the key features contributing to their effectiveness were:

• use of experiential learning 

• provision of feedback 

• effective peer/colleague relationships 

• well designed interventions following established educa- tional principles 

• use of a diversity of educational methods within single interventions.

PGME의 주요 특징

KEY FEATURES OF POSTGRADUATE MEDICAL EDUCATION

PGME는 UME와 많이 다르다.

Postgraduate medical education takes place in a very different environment.

근무지 기반 학습

Work based learning

Work based learning에서 최근 관심을 받기 시작한 몇 가지 영역

A number of areas of work based learning have roused interest in recent years.

• Eraut가 'non-formal learning'이라고 지칭한 것: 전문직과업 수행 중, 혹은 과업과 과업 사이에 발생하는 학습으로서 종종 학습자는 자신이 배운 것도 인식하지 못하기도 한다.
  The first of these is what Eraut30 31 terms non-formal learning—the learning that takes place during or between professional tasks, some- times even without the participant having been aware of what was learned.

• 도제식 모델로서 Master가 되기 위한 지식/술기/태도를 습득할 것으로 기대하며 직무에서 시간을 보내는 것. Lave and Wenger는 이러한 사회-문화적 발달을 ‘‘legitimate peripheral participation in a commu- nity of practice’’라고 지칭했다.
  Second is the apprentice model of education in which initiates spend time on the job in the hope that they will acquire the knowledge, skills and professional attitudes neces-sary to become a master.  Lave and Wenger32 famously characterised this socio-cultural progression from newcomer to old-timer as ‘‘legitimate peripheral participation in a commu- nity of practice’’, a process by which the novice learns to talk- the-talk and walk-the-walk.

• 마지막으로, interprofessional learning 이 있다. 진료의 퀄리티와 협력을 향상시키기 위해 둘 이상의 전문직이 함께, 서로로부터, 서로에 대해서 배우는 것
  Finally, there is an increasing focus on interprofessional learning in which ‘‘two or more professions learn with, from and about each other to improve collaboration and the quality of care’’.33

관리감독

Supervision

PGME의 상당부분은 동료간 전문적 대화의 결과로 이뤄진다.

A great deal of postgraduate education takes place as a result of professional conversations between colleagues.

이러한 '대화'를 가리키는 용어는 무척 다양한데, Launer는 "supervision"이라는 포괄적인 용어를 사용하였으며, 이것은 development 혹은 performance 혹은 둘 다에 초점을 둔 것으로, 대화의 맥락에 따라 달라진다

The terminology in this area is overlapping and frequently confused, though Launer has help- fully brought much of the literature together under the blanket term ‘‘supervision’’—a concept that may focus on development or performance or both, dependent on the context of the conversation.34

이것은 영국만의 문제는 아닌 것으로 보인다. 미국에서도 교수개발의 local delivery에는 문제가 많다.

And this is not just a UK problem. Evidence suggests that local delivery of faculty development in the USA is also problematic.23

적어도 영국에서는, 병원 바깥에서의 그림이 더 장미빛이다. 일부 경우에서 GP는 trainer를 교육할 경우 합당한 인정을 받는데, 세션당 혹은 주당 훈련에 대해서 보상을 받는다.

Outside hospital, in the UK at least, the picture is more rosy. For some time, general practice has given due recognition to its trainers, who receive a one session/week training payment, as well as 100%reimbursement of the trainee’s salary.

어디로 가야할 것인가?

WHERE NEXT WITH FACULTY DEVELOPMENT?

PGME에서 퀄리티에 대한 논의가 등장하고 있으며, clinical teacher에 대한 요건은 높아지고 있다. PMETB는 generic quality domain에 대한 요건expectations을 발간했으며, Gold Guide to Specialty Training도 training requirement를 내놓았다.

A quality agenda for postgraduate medical education is emerging, with heightened requirements for clinical teachers already in view. PMETB has published its expectations of training in a set of generic quality domains38 and the Gold Guide to Specialty Training39 has laid out the training requirements for clinical and educational supervisors.

이러한 발전은 consultant에만 국한되지 않으며, trainee도 ‘‘teacher training’’ 이 인턴, 레지던트 수련과정에 포함되어 이 요건을 만족시키기 위해서는 training course를 밟고자 할 것이다.

This development will not be confined to consultants, and trainees will want to undertake training courses before qualifying as requirements for ‘‘teacher training’’ feature in both Foundation and specialty training curricula.

핵심이슈는 funding과 교육의 의의를 중시하는 직무계획일 것이다.

The key issues will be to engage the service in the business of education, which will be largely dependent on how the funding of training posts is orchestrated in the future, and to negotiate meaningful job plans that value education as a core, rather than as a peripheral activity.

6. Kaufman D, Mann K. Teaching and learning in medical education: how theory can inform practice. In: Understanding medical education. Edinburgh: Association for the Study of Medical Education, 2007.

38. Postgraduate Medical Education and Training Board. Generic standards for training. 2006. http://www.pmetb.org.uk/fileadmin/user/Policy/Policy_Statements/ Generic_standards_for_training_April_06.pdf (Accessed 4 February 2008).

39. Department of Health. A guide to postgraduate medical education in the UK (The Gold Guide). MMC: Department of Health, 2007.

Postgrad Med J. 2008 Jul;84(993):339-43. doi: 10.1136/pgmj.2008.068288.

See one, do one, then what? Faculty development in postgraduate medical education.

교수개발(Editorial, Med Educ, 2005)

Faculty development

John Bligh

변화는 조직에 작용하는 힘이 아니다. 변화란 조직이 헤엄치고있는 바로 그 물이다.

 …change is not a force acting on organizations, but the very water in which organizations swim.  

Watkins and Mohr, 2001, xxxii,1

의학교육자에게 있어서 성공적인 교수개발은 교육능력의 향상을 가져올 것이며, 학생과 의사들이 더 나은 학습성과를 달성하게 해줄 것이다. 교수개발을 통한 향상에는 다음이 있을 수 있다.

For medical educators, successful faculty development results in improved teaching performance and leads to better learning out- comes for students or doctors. These improvements may include:

• 새로운 교수법, 평가법 the development of new teaching skills or assessment techniques which may be directed towards improving clinical care through better teaching;

• 더 나은 교육과정의 계획과 도입방법과 이를 통한 전 기관의 퍼포먼스 향상 better ways of planning or implementing a curri- culum or course, and hence improving institutional perform- ance;

• 교수-학생 관계에 대한 생각 전환 new ways of thinking about the student-teacher relationship;

• 과목 평가와 피드백에 더 몰입(참여) greater engagement with course evaluation and feedback;

• 교육분야의 학자됨(스칼라십) increased commitment to educational schol- arship, and

• 임상의사-교사로서의 태도 향상 improved attitudes to the task of being a clinician– teacher.4

효과적인 교수개발프로그램의 또 다른 성과로는 교수들의 사기morale을 진작시켜서 교수의 retention이 향상될 수 있다. 또한, 당연하지만, 교수개발프로그램이 한 기관 내에 존재할 때 그것은 그 기관의 문화와 가치를 반영한다. 교수개발프로그램은 한 기관이 그 기관의 인력에 대해서 가지고 있는 내면의 신념이 겉으로 드러난 것이다. Medical Teacher의 가치/신념/행동이 의학교육의 잠재교육과정의 상당한 부분을 구성하듯, workplace의 특성과 기관의 교육문화는 교수개발의 잠재교육과정에 중요한 역할을 한다.

Another outcome from effective staff development programmes is improved staff morale resulting in better staff retention; and, of course, the presence of staff devel- opment programmes within an institution is a reflection of the culture and values of the institu- tion. Faculty development pro- grammes are outward signs of the inner faith that institutions have in their workforce. Just as the values, beliefs and behaviours of medical teachers make up a substantial part of the hidden curriculum of med- ical education, so the nature of the workplace and the educational cul- ture of an institution play an important role in the hidden cur- riculum of faculty development.

종종 우리는 교수들도 학습자라는 사실을 잊곤 한다. 학생을 위한 프로그램을 만들 때 우리는 centering을 생각한다. 즉, 교사와 학습자의 관계에 있어 어느 쪽도 dominate하지 않고, 어느 쪽도 prevail over하지 않게 하는 것이다. 또한 어떻게 학생들의 기여하는 것의 가치를 인정해줄 것인지 생각하며, 교육상황teaching occasion에 교사와 학생이 bring to하는 학생의 요구/관점/생각을 어떻게 존중할 것인지를 고민한다. 이러한 원칙은 교수개발 에도 동일하게 적용된다.

Some- times we forget that faculty are learners too. When planning pro- grammes for our students we think about centreing – balancing the relationship between teacher and learner so that neither dominates and no one approach prevails over another; about how best to value our students and their contribu- tions; and about respecting the needs, views and ideas that teacher and learner bring to the teaching occasion. These principles apply equally to faculty development activities.

Irby and Wilkerson 에 따르면 거의 모든 의과대학은 어떤 형태로든 교육과정의 개편과 교육혁신을 진행하고 있으며, 따라서 의사가 교사로서의 전문성을 갖추기 위한 개발은 오늘날 그 어떤 때보다 더 중요할 것이다. 긍정적인 신호는 TD에 모든 의과대학 졸업생은 교수-학습의 원칙을 aware해야 한다는 것이 포함되었다는 것이다.

According to Irby and Wilkerson  almost every medical school has some form of curriculum renewal or educational innovation in pro- gress  so the professional develop- ment of clinicians as teachers is important, perhaps even more today than in recent years.6 One very positive sign for the future is the inclusion in Tomorrow’s Doctors of a recommendation that all medical graduates should have an aware- ness of the principles of teaching and learning.11

한 가지 확실한 것은, 효과적인 교수개발은 교수들이 우려하는 것, 아이디어, 열망이 무엇인지 경청하고 능동적 참여와 교육 프로세스에 대한 관심을 장려해야 한다는 점이다.

One thing seems certain though – effective faculty development involves listening to faculty about their concerns, ideas and aspira- tions and then encouraging active involvement and engagement in the educational process.

7 Suchman AL, Williamson PR, Lit- zelman DK, Frankel RM, Mossber- ger DL, Inui TS et al. Toward an informal curriculum that teaches professionalism. J Gen Intern Med 2004;19:501–4.

8 Pololi L, Frankel R. Humanising medical education through faculty development. Med Educ 2005;39: 154–62.

Faculty development.

의학교육환경 해부: 교수개발의 관점에서 본 잠재적 교육과정(Acad Med, 2011)

Decoding the Learning Environment of Medical Education: A Hidden Curriculum Perspective for Faculty Development

Janet P. Hafler, EdD, Allison R. Ownby, PhD, Britta M. Thompson, PhD, Carl E. Fasser, Kevin Grigsby, DSW, Paul Haidet, MD, MPH, Marc J. Kahn, MD, and Frederic W. Hafferty, PhD

과학과 배움을 촉진하는 요소로서 비공식적 사회적 요인(informal social element)의 중요성은 더 이상 과장하기 쉽지 않다.

It is, I think, not easy to exaggerate the importance of the informal social element in the promotion of science and learning. 

—Abraham Flexner, 1930

최근 수년간, 의학교육자들은 의사가 되어가는 프로세스에 있어서 공식-명시적 차원과 잠재-암시적 차원을 구분하는 것의 중요성을 인정하기 시작했다. 잠재교육과정은 (후대로) 전달되는 문화적 풍습으로서, 공식 혹은 비공식 교육educational endeavor에서 드러내놓고 인정되지는 않는 것이다.

In recent years, medical educators have acknowledged the importance of differentiating between formal-explicit and hidden-tacit dimensions in the process of becoming a physician. The hidden curriculum refers to cultural mores that are transmitted, but not openly acknowledged, through formal and informal educational endeavors.2–4

우리는 "교수개발"을 포괄적인 의미에서 사용하고자 한다.

We use the term “faculty development” in a broad sense, referring to

the inclusive range of learning that socializes faculty to their role, including professional and identity development, instructional development, leadership development, and organizational development.

이러한 분야의 학습은 어떻게 교수가 생각하고, 행동하고, 되어야be하는지에 대한 명시적이고 암시적인 경험을 포함한다.

These areas of learning often entail both explicit and tacit learning experiences related to how a faculty member should think, act, and be.

모든 학습에는 공식-명시적 요소와 비공식-암시적 요소가 다 있다. 적어도 지난 세기에는 교육자들은 학습에 대해 이러한 관점을 공유하고 있었다 그 예시로는 John Dewey의 collateral learning 이라는 개념이 있었으며, 더 근대적인contemporary 것으로는 workplace learning,6 situated/cognition learning,7 peripheral participation,8 and communities of practice9 등이 있다.

All learning involves both formal-explicit and informal-tacit elements. For at least the past century, educators have shared this view of learning. Examples include John Dewey’s5 concept of collateral learning as well as more contemporary concepts such as workplace learning,6 situated/cognition learning,7 peripheral participation,8 and communities of practice.9

비록 교육자들이 '공식'과 '비공식'을 구분하기 위하여 다양한 용어를 사용해왔지만, 이 모든 것의 기본적은 공식(법)과 비공식(문화적 전통, 비공식 규범, 고정관념, 사회적 실천)의 복잡한 상호작용이 일반적인 사회생활social life in general이라는 개념이었다.

Although educators have used a variety of terms to differentiate between the formal (e.g., explicit, written, curriculum on paper) and the informal (e.g., hidden, implicit, unwritten, meta, latent, shadow, tacit, tested) dimensions of medical learning, the basic distinction all of them make is that social life in general is governed by a complex interplay of formal laws and/or cultural traditions and informal norms, stereotypes, and social practices.10

의학교육자들 등이 학습환경을 공식과 잠재 교육과정의 이분법으로 나눠서 봐온 반면, 사회적 학습social learning의 현실은 보다 복잡한 현상이다. 어떤 식으로 부르든지, 세 가지 중요한 영역이 있다.

Whereas medical educators and others tend to view or describe the learning environment as a simple dichotomy between the formal and hidden curricula, the reality is that social learning is a more complex phenomenon.11,12 Regardless of the labels used, three critically important arenas of influence remain:

(1) 공식적으로 구조화되고 의도되었던 사회적 활동 those social activities formally structured and intended,

(2) 비공식적이고, 무계획적으로, 대본에 없던unscripted 사회적 활동 those social activities that are more informal, unplanned, and unscripted, and

(3) 조직문화나 공간place와 같은 보다 그 존재와 영향이 invisible하고 ethereal한 것을 those influences, such as organizational culture and place, that are more invisible and ethereal in their presence and impact.1,12,13

우리는 이 세 가지 영역이 학생 뿐 아니라 교수에게도 존재함을 말하고자 하며, "잠재 교육과정"이라는 용어를 숨겨져 있는hidden 모든 비공식적 영향을 포괄하는 의미로 사용하고자 한다(즉 2와 3을 합한 것)

We suggest that these three arenas exist not only for students but for faculty as well, and we will use the term“hidden curriculum” to globally capture all of the nonformal influences including those that are hidden (i.e., those captured in arenas 2 and 3),

학생과 교수 모두에 대한 잠재교육과정

Hidden Curricula for Both Students and Faculty

조직문화의 암시적, 비공식적 영역에 더 민감해지기 위해서는 교수형성faculty formation에 대한 잠재적 영역을 이해해야 한다. 예를 들어 매년 교육 관련 상을 수상하는 사람의 이름을 열거할 수는 있지만, 이러한 상award가 학교의 학샘 가치와 어떻게 연결되는지에 대해서는 명확히 설명하지 못할 것이다. 실제로, universe of award를 의도적으로 분석한 대학은 거의 없다.

We believe that a better understanding ofthe hidden dimensions of faculty formation will allow organizations to become more sensitive to the tacit and more informal dimensions of organizational culture. For example, faculty and administration may be well able to list the teaching awards and recognitions given out each year. However, they may be less able to articulate the characteristics of those awards relative to core school values.  Indeed, a school that has purposefully reviewed its universe of awards is rare.

잠재교육과정을 이해하는 것은 (심지어 그 메시지를 발송하는 사람조차 기존에는 알지 못했고 의도하지 않았다고 하더라도, 혹은 그 메시지를 받는 사람조차 인식하지 못하거나 잘 못 이해하고 있었더라도) 교수와 행정가들이 그러한 메타-메시지의 존재와 영향에 보다 민감해지도록 만들 수 있다. 메타-메시지를 이해하는 것이 중요한 이유는, 그러한 지식이 긍정적인 메시지를 늘릭, 부정적인 메시지와 의도하지 않은 결과를 최소화시키는 토대가 될 수 있기 때문이다.

Understanding the hidden curriculum can sensitize faculty and administrators to the existence and impact of such meta- messages, even if—perhaps especially important if—these messages are previously unseen and unintended by the sender or unrecognized and misinterpreted by the audience. Knowing the meta-messages is important because such knowledge provides the foundation for leveraging positive messages and minimizing negative messages and their unintended outcomes (e.g., high rates of faculty turnover, low faculty morale, decreased faculty productivity, decreased student satisfaction [with faculty], and ultimately poor organizational performance).32–36

교수개발을 잠재교육과정의 관점에서 재구성하기

Reconstructing Faculty Development From a Hidden Curriculum Perspective

의학교육 문헌에서는 종종 '교수개발'을 다음의 의미로 사용한다.

The medical education literature often employs the term“faculty development” to indicate

a particular set of educational activities, typically aimed at building skills in specific areas, such as grant and manuscript writing, curriculum development, and teaching.37–39

잠재교육과정의 관점에서, 교수개발은 특정한 공식적인 스킬-개발 경험으로 국한되는 것이 아니라, 더 포괄적인 개념으로서의 사회화와 연결된 generic process이다. 다른 말로는, 교수의 일원이 된다는 것은 (공식/명시적, 비공식/암시적 차원의 학습으로부터 영향을 받는infused) 광범위한 사회적 실천을 포함하는 직업적 문화화occupational enculturation의 프로세스이다. 이러한 관점에서 기존의 공식적 교수개발프로그램이 가지는 교육적 가치/영향/관련성은 더 넓은 범위에서 교수들이 "좋은 교수의 일원이 되는 것", "자신의 커리어 개발에 진짜로 필요한 것"은 무엇인가에 대해서 실제로 겪으면서 배우는go about learning 문화적 메시지의 한 부분일 뿐이다.

In terms of the hidden curriculum, faculty development exists not only as specific, formal skill-building experiences but also as generic processes tied to the broader concept of socialization. In other words, becoming a faculty member is a process of occupational enculturation that involves a broad range of social practices infused with both formal/explicit and informal/implicit learning dimensions. From this perspective, efforts to improve the instructional value, impact, and/or relevance of formal faculty development programs will be dictated in part by the broader array of cultural messages that faculty encounter as they go about learning what being a “good faculty member” means and what they really need to attend to in order to advance their careers.

"all politics is local"이라는 말을 인용할 수 있다. 의학교육에 있어서 "모든 학습은 - 그것이 학생 수준이든 교수 수준이든 - 맥락 의존적이다". 따라서 의과대학이 공식적 교수개발프로그램에 투자함으로써 faculty as teacher의 효과성을 높이고자 한다면, (teaching track과 같은) 교육을 교수의 가치로운 활동으로 인정해주는 더 포괄적인 문화적 지원이 무엇인가를 고려해야 한다. 만약 교수들이 근무환경에서 교육이 별로 대접받지 못한다는 상반되는 메시지를 전달받는다면, 공식적 교수개발의 노력은 그러한 문화에 의해서 약화되고 말 것이다. 예를 들어 주니의 교수가 시니어 교수들은 저널클럽에 참여하지 않는다는 것을 알게 되면, 그것이 academic life에 별로 가치가 없는 것이라고 생각할 것이다. 이 경우, 공식적 교수개발 프로그램의 한 부분으로 기획된 활동은 그 목표를 달성하는데 효과적이지 못할 것이며, 왜냐하면 더 넓은 문화broader culture가 공식적 교수개발 프로그램에 반하여 작동하기 때문이다.

To quote long-time Speaker of the House Thomas P. “Tip” O’Neil, “all politics is local.”40 In the case of medical education, all learning, be it at the student or faculty level, is context dependent.41 Thus, when a medical school invests in formal faculty development programs to increase the effectiveness of its faculty as teachers,37,38 it must also consider the broader cultural supports for teaching as a valued faculty activity, such as the presence (or absence) of a teaching track that includes tenure. If faculty members are receiving countervailing messages from their work environment that teaching is relatively undervalued, then the formal faculty development efforts to improve teaching skills are being undermined by the broader culture of the institution. For example, junior faculty who attended did not see senior faculty in attendance and may have interpreted the journal club as less valued in the schema of academic life at the institution. In this case, a planned activity created as part of a formal faculty development program was less effective in meeting its objectives because the broader culture, ran counter to the goals of the formal faculty development program.

Steinert 등은 대부분의 교육 향상을 위한 교수개발프로그램은 특정 유형의 교수들(진료의사, 특히 가정의학과, 내과)만을 대상으로 한다고 지적하였다. 또한 교수개발이 context가 부족하여서 "교사의 ongoing 교육활동과의 직접적 연결"을 만드는데 실패한다고 지적했다. 이러한 문제를 더 악화시키는 것은, 교수개발 intervention이 이론적 프레임워크가 부족하다는 사실이다.

Steinert and colleagues41 note that most faculty development programs target teaching and instructional improvement or they target a particular type of faculty, such as practicing clinicians, primarily those within family medicine and internal medicine programs (basic science faculty members receive far less attention). They further note that faculty development often lacks context and fails to establish “a direct link to teachers’ ongoing educational activities.”41 Compounding this problem, many faculty development interventions lack a theoretical (e.g., experiential learning, reflective practice) framework.

평가의 한계: 학습자의 반응이나 AKS의 변화에 초점을 두며, 실제로 학습자의 행동이나 시스템의 변화가 있었는지에 대해서는 잘 이뤄지지 않는다. politics is local이라는 아이디어에 기반하여 Steinert 등은 "맥락이 핵심이다context is key"라고 하였으며, 교수개발을 위한 노력 역시 조식의 문화에 보다 관심을 기울어여 한다고 했다. 더 중요하게는, 이들 저자들은 공식적 교수개발 프로그램이 Kirkpatrick의 처음 두 수준을 변화시키는데는 도움이 되지만, 변화를 위한 지지적 직업환경이나 보상체계를 만들지는 못한다(Kirkpatrick의 뒤쪽 두 수준)고 지적했다.

Studies of impact also focus more on learners’ reactions to the experience (e.g., favorable versus unfavorable) and/or changes in learners’ attitudes, knowledge, and skills rather than actual changes in the learners’ behavior or changes in the systems in which faculty and learners work.42 Reflecting the idea that politics is local, Steinert and colleagues41 conclude that “context is key” and that faculty development efforts must include more attention to organizational culture. More important, these authors41 conclude that whereas formal faculty development is able to address the first two of Kirkpatrick’s43 four necessary conditions of change (e.g., a personal desire to change and knowledge regarding the whats and hows of change), it is not able to create a supportive occupational environment or rewards tied to change (the last two of Kirkpatrick’s necessary conditions for change).

잠재교육과정에 관한 개념모델

A Conceptual Model for the Hidden Curriculum With Respect to Faculty Development

교육에 들인 시간을 근거로 각 과에 예산을 할당한다는 mission-based budgeting이 있을 때, 겉으로 보기에 이것은 교육에 투자하는 시간을 가치롭게 여긴다는 것 처럼 보일 수 있다. 그러나 이러한 예산의 분배에 있어서 과장department chair이 할당받은 예산을 연구 혹은 기타 다른 활동에 사용한다면, 이것이 교수들에게 어떤 메시지를 전할 것인가?

An example of this is mission-based budgeting that funnel dollars to its departments based on the time devoted to teaching. This structure, on the surface, may seem to value time spent teaching; however, if the allocation of those funds is left up to a departmental chair who chooses to funnel the money to researchers or other departmental activities, then what does this say to the teaching faculty within that department? 

미래를 바라보기

Looking Ahead

교수가 교육과 상충하는 목표에 대한 메시지를 얼마나 자주 받는가는 연구된 바가 없으며, 의학교육의 잠재교육과정에 대한 연구에서도, 교수개발에 대한 연구에서도 마찬가지이다. 의과대학의 문화와 교수개발과 관련하여 중요한 질문을 던져야 한다고 생각한다.

The likelihood for faculty to encounter a variety of conflicting messages about the nature and goals of their educational undertakings is not well understood, nor is it well documented in either the medical education hidden curriculumliterature or the faculty development literature. We suggest a critical need for empirical research to address important questions with respect to institutional culture and faculty development. Faculty face inconsistencies in the culture and structure of their workplaces, ambiguities about the nature of their work, and questions related to their professional identities.

Decoding the learning environment of medical education: a hidden curriculum perspective for facultydevelopment.

효과적인 의학교육자에게 필요한 특성과 책임(Acad Med, 2011)

The Educational Attributes and Responsibilities of Effective Medical Educators 

Charles J. Hatem, MD, Nancy S. Searle, EdD, Richard Gunderman, MD,

N. Kevin Krane, MD, Linda Perkowski, PhD, Gordon E. Schutze, MD,

and Yvonne Steinert, PhD

20세기 초반부터 미국 의학교육자들의 초점은 교육으로부터 연구와 진료로 변해왔고, 교육은 뒷전으로 밀려났다. 그러나 의학교육 연속체에 걸쳐서 교육스킬을 정교화refine해야 한다는 요구가 늘고 있고, 이와 관련된 교육 프로그램도 등장하고 있다. 교수들은 가르치는 법을 모른다는 사실만은 분명해 보인다.

Since the beginning of the 20th century, the focus for U.S. medical educators has shifted from teaching to research and clinical enterprise with teaching as a background activity.1,2 However, there are increasing calls for refinement in the teaching skills of faculty across the medical education continuum and relevant training programs have emerged.3–5 Clearly, faculty cannot not teach.

Medical Teacher의 특성과 역량을 개발하기 위한 프레임워크

Frameworks for the Development of Medical Teacher Characteristics and Competencies

Harden and Crosby는 효과적인 선생님의 skill set를 outline하면서 "교육은 부담이 크고demanding 복잡한complex 것이다"라고 했다.

Harden and Crosby,8 in an early study outlining the skill set of effective teachers, emphasize that “[t]eaching is a demanding and complex task.”

네덜란드의 TF는 핵심 교육 역량에 대한 포괄적인 프레임워크를 만들었다.

a national task force in the Netherlands offered a comprehensive framework of core teaching competencies, which allows for local institutional modification.9

Harden and Crosby는 교사의 레파토리를 반영하는 6개의 핵심 영역과 그에 따른 12개의 역할을 밝혔다.

Harden and Crosby8 identified 6 key areas and 12 derivative roles that reflect the teacher’s repertoire.

교사들은 시스템에서 하나 이상의 역할을 맡게 되는 경우가 흔하다.

teachers may, and frequently do, have one or more roles in the systemas well as in any given teaching encounter.

태도와 특질

Attitudes and Attributes

모든 교사에게 있어서 효과적인 교육이란 단순히 테크닉이 아니라, 배움과 이해가 달성되었느냐에 대한 것이다. 따라서 바람직한 skill set는 본질적으로 태도에 대한 것이다.

For all teachers, effective teaching is defined not by technique but by whether learning and understanding have been achieved. The bedrock of our desired skill set therefore is indeed a matter of attitude.

교육의 대변인이 된다

Advocates for education.

교육을 대변하고 대표하는 사람이 없이는 리소스의 배분 결정과 교육의 퀄리티가 고통받을 수 밖에 없다. 따라서 교사는 동료들에게 '교육의 mission을 remind'하는 것에 있어서 부끄러워 하지 말아야 한다.

Without advocacy and representation for this part of the mission in resource allocation decisions, the quality of education stands to suffer. Therefore, teachers must not shy away from reminding their colleagues about the mission of education.1

의학을 가르치는 교사로서의 윤리규범

Believes in a teacher’s code of ethics for teaching medicine.

Reiser는 교사를 위한 윤리규범을 저술하였다. 여기서 교사의 학생에 대한 책임은 정직함/신뢰/존중으로 학생을 대하는 것이며, 유사하게 교사에 대한 학생의 책임은 호혜성/정직성/개방성 등이다.

Reiser19 wrote a code of ethics for teachers In part, this code states that teachers’ duties to students should revolve around the attributes of candor, trust, and respect. Similarly, students’ duties to teachers are those of reciprocity, honesty, and openness.

교사로서의 열정을 보여주어라

Demonstrates passion as a teacher.

Wassermann은 t와 T의 교육을 구분할 것을 요구했다. t는 테크닉이며, T는 교육에 대한 열정으로, 호기심을 자극하여 학습자의 자기주도학습을 촉진하는 것을 포함한다.

Wassermann20 reminds us of the need to distinguish in our teaching the difference between t and T—between technique (t) and passion for teaching (T), including stimulation of curiosity along with fostering self-directed learning in the learners.

모든 대인관계interaction에서 친절하라

Demonstrates kindness in all interactions.

Osler의 숨겨진 모토는 "친절하게 하고, 가장 먼저 하라"이다. Osler가 친절에 대해서 지닌 감각은 환자와 피훈련자 모두에게 잘 알려져 있었는데, 왜냐하면 Osler가 "학우 여러분fellow student"라고 불렀기 때문이다.

A contemporary of Osler’s said that Osler’s unspoken motto seemed to have been, “Do the kind thing and do it first.”21 Indeed, Osler’s sense of kindness was well known to his patients and his trainees, whom he referred to as his “fellow students.”

Reilly는 임상교육에 대해서 다음과 같은 통찰력있는 기술을 한 바 있다.

Reilly,22 p710  who has written so insightfully about clinical teaching, offers enormously helpful observations:

"나도 잘 모른다"라는 말을 하는 것이 학생들에게 좋은 롤모델이 될 수 있는 것임에도, 많은 교육자들이 그렇게 마하는 것이 자신의 약점을 드러내는 것이라 생각한다. 그러나 학생이 그들처럼 교수도 '한계가 있구나limitation'라는 것을 이해했을 때, 이후에 더 발전해나갈 수 있는 공통 기반을 인식하게 된다.

Although using the phrase “I don’t know” is good role modeling for students, many educators feel that doing so is a sign of weakness. But once learners understand that a teacher has limitations just as they do, they begin to recognize a common ground on which to build.15

학습자들이 접근가능한 사람이 되라

Is accessible to learners.

교사는 (공식적으로 정해진 교육 시간 외에) 학생들이 접근가능한 사람이어야 하며, 이를 통해 학생에게 피드백을 주고, 평가를 하고, 간단한 조언을 줄 수 있다. 학습자는 어려운 질문이나 상황이 발생했을 때 교사를 만나는 것을 편안하게 느껴야 한다.

Teachers must be available to their learners to provide feedback, evaluation, or simple advice beyond the time set aside specifically for teaching. Learners should feel comfortable contacting teachers at any time if difficult questions or situations arise.

호기심을 자극하고 드러나게 하라

Manifests and stimulates curiosity.

교사가 지속적으로 호기심을 보이는 것은 효과적인 교수학습의 주된 촉매이다. 모든 것을 아는 듯한 인상을 주는 것 보다 모든 (학습)기회에서 지식을 진실되고 능동적으로 탐구해나가는 모습이 더 바람직하다.

Curiosity, on constant display by the teacher, is a prime catalyst for effective teaching and learning. Cultivating an image of omniscience is less appropriate than sincerely and actively seeking out knowledge at every opportunity.

학생을 이해하라

Seeks and obtains knowledge of learners.

사람의 상호작용을 보여주는 가장 근본적인 것 중 하나는 다른 사람의 이름을 알고 부르는 것이며, 이는 교육에서 특히 중요한 개념이다. Ferguson은 이렇게 표현했다.

One of the fundamentally validating human exchanges is to know— and use—another’s name, a particularly important precept in the educational arena. Ferguson,24 makes the point eloquently:

학생의 이름을 모르고서는 학생과 실질적인substantive 교류를 기대할 수 없다. 이것은 인간 본질의 법칙과 같은 것이다. 무엇의 이름을 아는 것은 그 것에 대한 흥미를 보여주는 근본적 의미이다.

You cannot hope for a substantive exchange with your students if you do not know their names. This amounts to a near law of human nature: your knowledge of the name is a primal signification of your interest….

안전한 교육 환경을 만들라.

Values and establishes a safe learning environment.

안전한 교육환경이란 조롱받을지도 모른다는 두려움이 없는 환경이다. '안전'을 느낌으로서 지식을 더 받아들일 수 있고, 자신이 모르는 것이 무엇인지 더 탐구할 수 있다.

The fear of being ridiculed should not have a place in the safe educational environment. From the feeling of safety comes a receptivity for knowledge and a willingness to explore one’s own ignorance.12,25

효고적인 롤모델이 되어라

Values and functions as an effective role model.

Albert Schweitzer는 "모범Example이란 타인에게 영향을 주는 주된 것이 아니다. 그것은 '유일한' 것이다." 라고 했으며, 이것은 '(교사가) 말하는 것'이 아닌 '(교사가 하는) 행동'의 힘을 보여준다.

Albert Schweitzer’s26 oft-quoted remark—“Example is not the main thing in influencing others. It is the only thing”—is a testament to the power of what we do versus what we say.

지식

Knowledge

학생을 하나의 인간으로서 이해하지 않고서는, 교육을 이끄는 사람으로서 교사의 능력은 성공할 수 없다.

Without an understanding of students as persons, the teacher’s ability to succeed as an educational guide is compromised.

기본적 교육 원칙을 인식하고 있음을 보여주고, 암시적 또는 명시적으로 활용하라

Demonstrates an awareness of and tacitly or explicitly employs basic pedagogic principles.

교육 프로세스는 교사가 가진 암시적 또는 명시적 지식에 따른다.

The teacher’s tacit and explicit knowledge informs the teaching process,

there is reason to believe that good knowledge and understanding of the basics of pedagogy can...

sensitize teachers to the process of learning,

provide logic for understanding repeated successes and failures, and

serve a critical function in informing teaching practice.28 p118 

최근의 신경과학과 인지심리학적 연구결과를 근거로 교육 테크닉을 활용하라

Displays awareness of and uses teaching techniques in line with current neuroscience and cognitive psychological findings.

기본적인 교육 원칙에 기반한, 인지 신경과학 연구가 늘어나고 있고, 이러한 내용이 교수개발 프로그램에 포함되어야 한다.

well-founded basic educational principles, and a growing body of literature links cognitive neuroscience findings with educational practice.28–31 ought to be included in faculty development programs

자신의 분야를 잘 알고, 최신지견을 알아야 한다.

Is knowledgeable and up-to-date in one’s discipline.

Irby는 임상 교사가 알아야 하는 것에 대해서...

Irby,16 p333  in studying what clinical teachers need to know, notes

Educational researchers assert that knowledge for teaching requires an in- depth and flexible understanding of subject matter. Teachers need to know their subject well enough to make connections within the subject, across disciplines, and with their learners. Alternative conceptions of content help teachers switch back and forth between the student’s, the discipline’s, the textbook’s, and their own conceptions.

스칼라십을 촉진하라

Promotes scholarship.

"기전mechanism을 임상과 분리시키는 교육은 가치가 없다"라고 했다. 창의적 교육과정이란 학습자가 기초과학 정보를 임상에서 recall하고 apply할 수 있는 능력을 강화시켜주는 것이다.

Indeed, “instruction that divorces mechanisms from clinical correlates will likely be of little value.”34 pS127  Creative curricula have been defined to enhance the learner’s ability to recall and apply basic science information at the bedside.35

교육 세팅에서의 리더십을 보여주라

Demonstrates leadership in educational settings.

새로운 리더십 스킬을 기르고, 발전시켜야 하며, 기관의 전반적 이익overall good을 위해 필요하다면 리더십 지위position을 기꺼이 맡아야 한다.

They should also be able to grow and develop new leadership skills and willingly take leadership positions that may be required for the overall good of the institution.

효과적인 강의 스킬, 소그룹- 대그룹- 토론의 촉진 스킬

Demonstrates the basic skills for effective lecturing and facilitating small- and large- group discussion.

질문하고, 경청하교, 효과적으로 반응하라

Questions, listens, and responds effectively.

Self-reflection, peer review, learner input, and a well- organized framework for questioning, listening, and responding

"교육과 지속적 학습의 프로세스의 가치를 중시하는" 학습 커뮤니티를 설립하라

Establishes a learning community “that values education and the process of continual learning.”42 p387 

Osler가 학생을 "학우 여러분"이라고 칭한 것은 그가 교수-학습을 "쌍방향적 지적 교환"으로 바라본 신념을 훌륭하게 나타내주는 말이다. 이러한 마음가짐은 교수와 학생 사이에 공유되는 공동의 책임을 시사한다.

Osler’s referring to his learners as “fellow students”43 p247  wonderfully captures the spirit of the bidirectional intellectual exchange found in teaching and learning. This mindset implies a communal responsibility for education shared among its members.

학습자와 교육계약을 맺고, 학습자의 요구를 확인하고, 교사가 기대하는 것을 명확히 한다.

Establishes an educational contract with learners, identifying learners’ needs and clarifying the teacher’s expectations.

Pratt and Magill는 교육계약의 개념을 이미 30년 전에 도입했다. 이 개념은 teaching encounter의 네 가지 핵심 요소를 드러내는 것이다

Pratt and Magill44 p463  introduced the concept of educational contracts nearly three decades ago. This concept of identifying four key elements in the teaching encounter—

• 학습자의 니즈 needs of learner,

• 교사의 기대 expectations of teacher,

• 역할에 대한 토론 discussion of roles, and

• 과목 내용에 대한 토론 discussion of course content—

교육계약이란, 학생과 제일 처음 만나는 그 시점에서, 교사가 학습자를 프로세스의 파트너로서 초청하는 것이다.

It is, at the very beginning of the educational encounter, a tangible expression by the teacher of inviting the learner to be a partner in the process.

다섯 째 요소는 학습기간동안 상호 피드백을 예정하는 것이다. 이것이 교육 계약에 포함되어야 한다. 교육 계약은 한번 정해지면 끝나는 것이 아니라, 시간에 따라 니즈나 기대가 변하면서 다시 보고viewed, 유기적으로 활용되어야 한다. 

A fifth crucial element—arranging for mutual feedback during the learning period—must also be added to the educational contract. Educational contracts are not static devices; they ought to be viewed and used organically as needs or expectations change over time.

자기성찰적, mindful한 교사

Is a reflective, mindful teacher.46

reflection과 mindfulness를 위해서는 안전한 교육 환경이 필요하다

Reflection and mindfulness require a safe learning environment, as we’ve noted.

많은 경우, 가르치는 것은 공연performing art과 같다. Timpson and Burgoyne는 "teaching을 준비하는 방법으로 공연performing보다 나은 것은 없다. 왜냐하면 그 두 가지의 과제는 똑같기 때문이다. 사람들의 이목을 끌고 집중을 유지시키는 것이다"

In many ways, teaching is a performing art. Timpson and Burgoyne48 p15  suggest, “There is no better preparation for teaching than performing because the challenges are the same—getting people’s attention and holding it.”

교육적 리스크를 지는 것을 두려워하지 말아야 하며, engaged teaching의 즐거움을 보여주는 것을 망설이지 말아야 한다. 교사는 훌륭한 스토리텔러이다.

They are not afraid to take educational risks, nor are they reluctant to demonstrate the joy of engaged teaching. Teachers are good storytellers.

비판적 사고를 촉진하라

Promotes critical thinking.

'비판적 사고는 교육하고 학습할 수 있는 인지적 기술이다'

it has been suggested that “[c]ritical thinking is a cognitive skill that can be taught and learned,”49 p342  though not without its own challenges.50

Harasymand 등은..다음과 같은 방법을 사용할 수 있다고 했음

As Harasymand colleagues49 p350  note,

There are multiple educational strategies that teachers can use …

• student-focused, active learning,

• type of assessment methods,

• early patient exposure,

• integration of basic and clinical sciences,

• learning objectives …

• multiple learning methods, and …

• broad picture first followed by details, or details presented first to create the broad picture.

자기주도 학습을 촉진하는 교사

Promotes self-directed learning.

적시에 총괄평가를 시행하는 교사

Provides timely summative evaluation.

부담스럽더라도, 교사는 총괄평가를 효율적으로, 진실되게 수행해야 한다. 그리고 교육경험이 종료되는 시점과 총괄평가가 진행되는 시점 사이의 시간은 짧아야 한다(?)

Despite multiple time demands, teachers are responsible for doing this efficiently, honestly, and with the least amount of time between the end of the educational experience and the submission of a summative statement.31

정보테크놀로지를 효과적으로 활용

Uses information technology effectively.

기본적 원칙에 충실해야 한다.

Because these technologies evolve rapidly, faculty members need to focus on fundamental principles of teaching and learning rather than specific technologies.52

교육 AKS 촉진을 위한 교수개발

Faculty Development to Promote Educational AKS

다음의 권고안.

the following recommendations concerning teacher competencies emerged fromthe 2020 Vision of Faculty Development Across the Medical Education Continuum conference7:

1. Institutions must fund and value a cadre of faculty whose central responsibility is to teach in the same way they value faculty with the responsibility of clinical care and research.

2. Institutions must provide evidence that they have addressed both individual and organizational needs by employing a variety of faculty development programs.

3. External funding must be available for centers of excellence in faculty development.

4. A nationally derived, evidence-based set of competencies for teaching across the medical education continuum must be established and promulgated. (Our list of AKS could serve as a starting point.)

5. Accrediting bodies must require institutions to ensure that teachers develop and demonstrate the achievement of evidence-based teaching competencies.

The literature underscores that comprehensive faculty development programs cannot focus solely on individual improvement; they must also address the increasingly complex institutions in which teaching and learning occur.52,53 And, vitally, all teachers need to bear in mind their important responsibilities to ensure that academic health centers remain true to medical education as one of their core missions. It is ironic that in an academic environment one must make the argument for demonstrated teaching abilities as a necessary prerequisite to their exercise.

7 Baylor College of Medicine. Faculty Development Conference: A 2020 Vision of Faculty Development Across the Medical Education Continuum; February 26–27, 2010; Houston, Tex. http://www.bcm.edu/ fac-ed/?PMID 15709. Accessed December 17, 2010.

17 HatemCJ, Lown BA, Newman LR. Strategies for creating a faculty fellowship in medical education: Report of a 10-year experience. Acad Med. 2009;84:1098–1103. http://journals. lww.com/academicmedicine/Fulltext/2009/08000/ Strategies_for_Creating_a_Faculty_Fellowship_in. 28.aspx. Accessed December 17, 2010.

18 Norman G. Teaching basic science to optimize transfer. Med Teach. 2009;31:807–811.

22 Reilly B. Inconvenient truths about effective clinical teaching. Lancet. 2007;370:705–711.

39 Newman L, Lown B, Jones R, Johansson A, Schwartzstein R. Developing a peer assessment of lecturing instrument: Lessons learned. Acad Med. 2009;84:1104–1110. http://journals.lww. com/academicmedicine/Fulltext/2009/08000/ Developing_a_Peer_Assessment_of_Lecturing. 29.aspx. Accessed December 17, 2010.

The educational attributes and responsibilities of effective medical educators.

의학교육에서 변화하는 교육 테크놀로지 역할에 대한 준비(Acad Med, 2011)

Preparing for the Changing Role of Instructional Technologies in Medical Education

Bernard R. Robin, PhD, Sara G. McNeil, EdD, David A. Cook, MD, MHPE, Kathryn L. Agarwal, MD, and Geeta R. Singhal, MD, MEd

고등교육기관이 진화하면서, 변화하는 트렌드에 따라서 급진적인 변화를 겪게 된다.

As institutions of higher education evolve, it is obvious that they, need to undergo radical changes to deal with the converging trends

Christensen이 Forum for the Future of Higher Education에서 지적한 바와 같이, 학교들이 교육내용의 전달에 대해서 다시 생각하고 다시 구조화할 때가 되었다. "이 리빌딩 작업을 위해서는 자신이 속한 과나 분과를 대표하지 않으면서, 현재의 조직 구조를 벗어나 생각할 수 있는 전문가 팀이 필요하다"

As Christensen1 notes in the Forum for the Future of Higher Education, schools must completely rethink and restructure the way they deliver educational content: “The rebuilding task demands a team comprising experts who don’t represent their departments or divisions and who can think outside the current organizational structure.”

미래 예측의 어려움

The Challenge in Predicting the Future

1936년 H.G. Wells는 "전 세계의 흩어지고 비효과적인 정신적 재산"을 위한 해결책으로 일반인을 위한 "World Encyclopaedia"라고 부르는 것을 제시했다. "World Encyclopaedia"는 각 분야의 권위자들이 집필assemble하며 (내용의) "집중, 명확, 종합"이 될 것이며, "전 세계를 정신적으로mentally 모아줄 것이다". Well이 말한 "World Encyclopaedia"는 2001년 Jimmy Wales와 Larry Sanger가 시작한 오늘날의 위키피디아와 매우 비슷하다.

In 1936, H.G. Wells3 suggested that the solution to “all the scattered and ineffective mental wealth of the world” was what he called a “World Encyclopaedia” for the common man. The World Encyclopaedia would be assembled by authorities in each subject area and would be “a concentration, a clarification, and a synthesis” designed to “hold the world together mentally.” Wells’ World Encyclopaedia sounds remarkably like today’s Wikipedia, a multilingual, Web-based, free-content encyclopedia project based on an editable, collaborative model begun in 2001 by Jimmy Wales and Larry Sanger.4

1945년 Vannevar Bush는 과학 커뮤니티의 연구결과를 관리하고 전파하는 것이 어렵다는 것을 느끼고 memex를 제안하였는데, 이것은 "개개인이 자신의 책/기록/커뮤니케이션 등을 저장하는 장치로서, 엄청나게 빠른 속도와 유연성으로 그 자료를 가지고 논의consult with 할 수 있게 해주는 장치"이다. 이 memex는 오늘날의 컴퓨터 또는 인터넷과 연결된 스마트폰과 매우 비슷하다.

In 1945, Vannevar Bush5 described the difficulty in managing and disseminating the results of research to the scientific community. He proposed the memex,a device in which “an individual stores all of his books, records, and communications, and which is mechanized so that it may be consulted with exceeding speed and flexibility.” The memex sounds surprisingly like today’s handheld computers and Internet- connected smartphones.

그러나 미래에 대한 예측이 늘 옳은 것은 아니다.

Yet not all predictions of the future are this accurate.

외과의사인 John Eric Erichsen는 1873년..."언제나 새로운 수술 필드fresh field가 있을 수는 없다...(후략)"이라고 했다

John Eric Erichsen,6 appointed Surgeon Extraordinary to Queen Victoria, stated in 1873: “There cannot always be fresh fields for conquest by the knife. There must be portions of the human frame that will ever remain sacred from its intrusion—at least, in the surgeon’s hand.”

William Thomson 는 X-ray는 사기이다 라고 했다. Kanter의 경고를 따르자면, "미래를 예측하는 것은 점쟁이의 역할이며, 우리는 의학교육을 발전히키기 위해서 미래에 어떤 기회가 있을지 예측하는 것이 최선이고, 혹은 최악의 경우에는 세계가 우리를 남겨두고 발전해 나갈 수도 있다."

William Thomson (Lord Kelvin), an English physicist and inventor, stated in 1899 that “X-rays will prove to be a hoax.”7 Acknowledging Kanter’s8 caution that predicting the future is best left to fortune tellers, we need to do our best to predict future opportunities to improve medical education, or worse, be left behind as the world moves on without us.

우리에게는 두 가지 중요한 과제가 남았다. 하나는 변화를 충분히 일찍 수용하여 결과에 영향을 미치는 것이고, 둘째는 변화를 활용하여 교육을 향상시키는 것이다.

We face two important tasks: first, to adapt to change early enough to influence outcomes; and second, to harness change to enhance education.

의학교육에 영향을 주고 있는 변화 트렌드

Converging Trends in Technology That Are Affecting Medical Education

1. 새로운 정보의 폭발

Trend 1: The explosion of new information

전 세계의 지식의 총체는 엄청난 속도로 빠르게 증가하고 있다. 1800년에서 1900년이 되면서 두 배가 되었으나, 1940년에는 20년이면 두 배가 되었고, Cornall은 2015년이 되면 35일마다 두 배가 될 것이라고 예상했다

The rate of growth of the world’s collective body of knowledge has been accelerating at an extraordinary pace. The world’s body of knowledge doubled between 1800 and 1900, by 1940 the doubling rate was every 20 years,9 and Cornall10 has postulated that by 2015, the body of knowledge in the world will double every 35 days.

2. 모든 정보의 디지털화

Trend 2: The digitization of all information

Google Health 는 모든 사람들이 자신의 의무기록, 처방 등을 모으고, 이 데이터를 가족이나 의사나 다른 사람들과 온라인으로 공유할 수 있다.

Google Health (https://www.google.com/health) now allows people who create an account to collect their medical records, prescriptions, and other health data and share them with family members, health care practitioners, and others online.

이것은 한 가지 사례일 뿐이며, 이러한 hyperconnectivity는 의학교육자들과 의료정책에 광범위한 사회적/개인적/윤리적 이슈에 관한 심각한 질문을 던지며, 이 질문은 사용자/부모/정책개발자/교육자들에게 tension을 일으킬 것이다.

Yet this growth of hyperconnectivity to the Internet and the Web prompts medical educators and policy makers to ask serious questions about a broad range of social, personal, and ethical issues that will almost certainly provoke tension among users, parents, policy makers, and educators.

학습자가 방대한 양의 디지털 정보에 접근가능하게 되면서, 이 정보센터의 파괴적 영향력을 활용하는 교육자만이 성공할 수 있게 되었다. Bonk는 "(교육)기관들은 지식을 생성하고/서포트하고/전파하고/소비하는 방식에 대한 새로운 기전을 만들어야 할 것이다"라고 했다.

As learners gain access to and control over increasing amounts of digital information, successful educators must take advantage of the disruptive effects this information creates. In Bonk’s14 view, “institutions will need to create new mechanisms for the way knowledge is created, supported, disseminated, and consumed.”

3. 새로운 세대의 학습자

Trend 3: New generations of learners

오늘날 대부분의 의학교육자들은 세 가지 카테고리로 구분된다.

Most medical educators today fall into one of three categories: “digital immigrants,” “digital settlers,” or “traditionalists.”

• "디지털 이주자": Prensky가 만든 용어로서, 공식교육을 받는 기간에는 컴퓨터를 접하지 못했다가 그 이후에 테크놀로지를 활용하게 된 집단. 대부분은 디지털 테크놀로지를 사용하나 약간의 "사투리with an accent"가 있다.
  “Digital immigrants,” a term coined by Prensky,15 describes those who learned to use technology after finishing a formal education without continuous access to computers. Most of these people now use digital technologies, but they do so “with an accent,” typical of someone who learned a new language as an adult.

• "디지털 정착자": Palfrey and Gasser는 이들을 "디지털 세상에서 태어나지는 않았으나" "디지털 세상에서 살아가는" 사람들이라고 묘사했다. 이들은 많은 테크놀로지에 익숙하고, 이들의 "사투리"는 "디지털 이주자"의 그것보다는 덜 심하다. 
  A smaller number of adults, including many educators and health care professionals, are “digital settlers,” described by Palfrey and Gasser16 as those who were not “born digital” but who “live digital” nonetheless. These adults feel comfortable using many technologies for professional and personal productivity, and their accent is decidedly less pronounced than that of their digital immigrant cousins.

• "전통주의자": 테크놀로지 없이 태어났으며, 교육 방법으로 테크놀로지를 수용하지 않음
  Another group, the “traditionalists,” grew up without technology and have not embraced it as a core part of their teaching.

"디지털 네이티브": Norris and Soloway는 교육이 혁신적 교육 전략을 집중적으로 활용하여 Prensky가 "디지털 네이티브"라고 말한 집단의 학생을 참여시킬 수 있어야 한다고 주장하였다. 이 세대가 의과대학에 들어오면서 세 가지 중요한 질문이 등장했다.
Educators such as Norris and Soloway17 suggest that change in educational practices should focus on innovative instructional strategies to reach and engage those students whom Prensky described as “digital natives.” As this generation of learners reaches medical schools, there are three important questions to consider:

• 어떤 유형의 학습자인가? What type of learners will these “digital natives” be?

• 이들은 교육 구조에 어떤 변화를 가져올 것인가? What changes will they precipitate in the way education is structured?

• 의학교육자들은 어떻게 이 학생들의 기대를 다룰 것인가? How will medical educators deal with these students’ growing expectations to integrate new technologies in the curriculum?

의학교육자들의 과제는 새로운 테크놀로지를 화교적으로 활용하여 보다 협력적인 학습과 개별화된 학습으로 만들고, 새로운 세대의 학습자를 inspire할 수 있는 경험을 만드는 것이다. Bonk는 테크놀로지의 새로운 시대를 "언제든 누구에게서든 무엇이든 배울 수 있는 시대(Anyone can now learn anything from anyone at anytime)"라고 했다.

The task for medical educators is to use these new technologies effectively to transform learning into a more collaborative, personalized, and empowering experience that can inspire a new generation of learners. Bonk14 captures the essence of this new age of technology tools for education by stating, “Anyone can now learn anything from anyone at anytime.”

디지털 비디오 클립은 거의 모든 주제를 다루고 있으며, 방대한 시청자가 능동적으로 비디오 평가에 창며하고, 비디오에 대한 반응을 올린다. 여기서 중요한 것은 사용자가 단순히 수동적 관람자가 아니라, 능동적으로 새로운 형태의 커뮤니케이션과 표현에 참여한다는 것이다.

Digital video clips on almost any topic can command a sizeable audience that also actively participates in the rating of the videos and the posting of video responses.18 The significance of this is that these users are not just passive viewers; many of them are actively engaged in a new form of communication and expression.

Web 2.0은 새로운 온라인 도구와 리소스를 말하는 것으로, 다양한 SNS, 가상환경, 위키, 블로그, 팟캐스트 등을 말한다.

Web 2.0, a term used to describe an evolving set of online tools and resources, includes a wide variety of social networking sites, virtual environments, wikis, blogs, and podcasts.20

웹을 글로벌한 서포트 그룹으로서 가능하게 하는 프로젝트에는 Patients Like Me21와 같은 것이 있다.

A project that enables using the Web as a global support group illustrates one of the disruptive effects of these new types of resources. Patients Like Me21

여러 Web 2.0 도구 뿐 아니라, Hi-Fi 시뮬레이터나 가상환자 등도 불과 몇 년 전만 해도 상상조차 못했던 새로운 학습경험을 제공해줄 수 있다.

In addition to the many Web 2.0 tools, new technologies such as high-fidelity simulators and virtual patients can provide new learning experiences that were unimaginable just a few years ago.

5. 점점 더 빨라지는 변화속도

Trend 5: Accelerating change

마이크로소프트는 2008년 'Being Human: Human–Computer Interaction in the Year 2020'에서 다음 10년간 개개인은 수천대의 컴퓨터, 즉 사실상 자신이 착용하고 있는 모든 것과 상호작용하게 될 것이다라고 했음

A 2008 report from Microsoft, Being Human: Human–Computer Interaction in the Year 2020,24 predicts that within the next decade, individuals will interact with thousands of computers as virtually every piece of equipment we use,

Gaudin는 2020년에는 키보드와 마우스가 더 이상 필요없어질 것이라 했음

Gaudin25 postulated that by 2020, the keyboard and mouse will no longer be needed to control a computer.

권고

Recommendations

권고 1: 테크놀로지를 활용하여 학습을 서포트하라

Recommendation 1: Use technology to support learning

교수는 (테크놀로지가 없었다면) 불가능했었을 경험을 학습자에게 제공하고 그러한 경험을 지원하여야 한다. 테크놀로지는 면대면 경험의 대체제가 아니라 그것의 보완제이다.

Faculty should use technology to provide and support experiences for learners that are not otherwise possible—not as a replacement for face-to-face experiences but as a supplement to them.

종종, 가장 효과적인 교육 디자인은 전통적인 것과 테크놀로지-강화 방법을 함께 사용하는combination 것이다. 그렇다면 질문은 "테크놀로지를 활용해야 하는가"가 아니라 "언제 어떻게 테크놀로지를 활용해야 하는가"이다.

Often, the most effective instructional designs involve a combination of traditional and technology-enhanced methods. The question, then, is not whether we should use technology to support education, but when and how to employ these technologies.

권고 2: 기본에 충실하라

Recommendation 2: Focus on fundamentals

테크놀로지가 빠르게 진화하면서 교수들은 (특정 테크놀로지가 아니라) 교수학습의 기본원칙에 더 충실해야 한다.

Because technologies evolve rapidly, faculty members should focus on fundamental principles of teaching and learning rather than specific technologies in isolation.

"테크놀로지"는 교육자들이 필요에 따라 적절한 도구를 선택하여 사용할 수 있는 도구상자의 역할을 해야 한다.

“Technology” thus assumes its appropriate role as a toolbox fromwhich educators may select the appropriate tool (or combination of tools), depending on the needs at hand.

• HEAL Several online resources provide ideas for how this online community can be structured. For example, the Health Education Assets Library (HEAL), developed in conjunction with members of the International Association of Medical Science Educators, is a digital repository that “allows medical educators to discover, download, and reuse over 22,000 medical education resources.”36 HEAL gives medical educators access to a wide range of multimedia resources that can support health care education.

• MedEdPORTAL MedEdPORTAL, a free, peer-reviewed publication service and repository for health-related teaching materials, assessment tools, and faculty development resources, is an example of an excellent online publication service designed to help educators publish and share teaching materials.37,38 The structure of MedEdPORTAL differs slightly from HEAL in that it typically publishes more complete, stand-alone resources such as tutorials, virtual patients, simulation cases, lab guides, videos, podcasts, and assessment tools.36

• BioMedExperts “BioMedExperts” is not a repository of resources but, rather, an online community that generates expert profiles by analyzing PubMed publications. It then connects researchers with similar expertise and interests to create professional networks and support collaboration and interdisciplinary research.39

미래는 이미 와 있다

The Future Is Here

비록 우리가 미래를 확실하게 예측하지는 못하지만 한 가지는 확실하다: 우리는 테크놀로지를 수용하고, 테크놀로지에 적용하고, 테크놀로지를 활용하여(embrace, adapt to, and harness) 현재와 미래 의료전문직의 요구에 부응해야 한다.

Although we cannot predict the future with certainty, one thing is clear: We must embrace, adapt to, and harness technology in order to meet the needs of present and future health professionals.

2 Baylor College of Medicine. Faculty Development Conference: A 2020 Vision of Faculty Development Across the Medical Education Continuum; February 26–27, 2010; Houston, Tex. http://www.bcm.edu/ fac-ed/index.cfm?pmid 15709. Accessed December 8, 2010.

Preparing for the changing role of instructional technologies in medical education.

학습에 관한 신경생물학으로부터 의학교육자들이 배워야 할 것(Acad Med, 2011)

What Can Medical Education Learn From the Neurobiology of Learning?

Michael J. Friedlander, PhD, Linda Andrews, MD, Elizabeth G. Armstrong, PhD, Carol Aschenbrenner, MD, Joseph S. Kass, MD, Paul Ogden, MD, Richard Schwartzstein, MD, and Thomas R. Viggiano, MD, MEd

지난 50년간 학습과 기억에 관한 생물학적 기초에 대한 이해가 크게 확장되었다.

Over the past 50 years, there has been an explosion in our understanding of the biological basis of learning and memory.

학습의 분자세포적 기초

A Brief Look at the Molecular and Cellular Basis of Learning

다양한 유형의 학습이 있다. 비연관nonassociative 학습, 연관associative학습, 지각perceptual학습, 운동motor학습 등.

There are many types of learning, including various forms of nonassociative and associative learning, perceptual learning, and motor learning.11–13

비록 기억이 일반적으로 과거 경험의 stable and precise representation으로 여겨지지만, 정확히 그 반대이다. 즉, 기억은 제시된 정보가 개인적 경험과 학습환경, 이후 일어나는 사건, 집중 정도, 스트레스 등에 적용(영향)을 받는 역동적 프로세스이다.

Although memories are generally considered as stable and precise representations of past experiences, they are often anything but that.2,13,16 That is, memory is a dynamic process where the information represented is subject to our personal experiences, the context of the learning environment, subsequent events, levels of attention, stress, and other factors.17–19

학습은 뉴런 사이의 네트워크에 기능적이고 구조적 변화를 일으킨다.

Learning leads to functional and structural changes in the interconnected cellular networks between neurons (synapses) at a variety of sites throughout the central nervous system.20–22

• 화학적 시냅스 전달의 변화 changes in the efficiency of chemical synaptic transmission

• 단백질의 번역후 modification posttranslational modifications of proteins located in proximity to synaptic contacts

• 시냅스-후 신경에 대한 시냅스-전 신경의 활동전위 presynaptic nerve impulse (action potential) at the postsynaptic neuron.

이러한 연구결과들이 strength와 정보의 반복 사이의 관계를 알려주었다.

This type of experimental work provides a direct link between the strength and/or repetition of the information

예를 들면, 일정 간격을 두고 연습을 하여 신경pathway의 반복적 activation을 줄 경우, 분자신호의 cascade를 일으키는데, 이것은 짧은, 소수의 연습을 했을 때의 것과는 다르며, 더 지속적이다.

For example, repeated activation of neuronal pathways participating in learning with appropriately spaced trials leads to a cascade of molecular signals that are different and more persistent than those that accompany briefer or fewer trials.26–28

개별 뉴런과 뉴런 네트워크간 커뮤니케이션의 효과성이 기능적으로 변화하면 뇌의 구조적 서킷circuitry에도 변화가 생기고, 예전에는 성인에서는 뇌의 구조적 서킷은 고정된 것hard wired라고 여겨졌었다.

The functional changes in the effectiveness of communication between individual neurons and networks of neurons are also accompanied by substantial changes in the structural circuitry of the brain,5,29 once thought to be hard-wired in adults.

교육과 교육과정 개발에 대한 함의

Implications for Medical Teaching and Curricular Development

보상과 강화

Reward and reinforcement

보상은 인생의 모든 단계에서 학습에 필수적 요소이다. 더 나아가 뇌의 내적 보상 시스템이 학습된 행동의 강화에 중요한 역할을 한다.

Reward is a key component of learning at all stages of life44,45 Moreover, the brain’s intrinsic reward system plays a major role in reinforcement of learned behaviors.47

흥미롭게도, 인간의 두뇌의 신경서킷은 temporal discounting을 겪는다. 즉, 어떤 선택의 상대적 가치는 즉각적인 보상과 더 먼 미래의 보상 사이에서 계산기를 두드린다.

Interestingly, the neural circuitry of the human brain engages in temporal discounting50—that is, the calculation of the relative value of a choice to realize a reward of a certain value in the immediate future versus a reward of a greater value in the more distant future.

학습understanding을 통해서 더 즉각적인 목표에 대한 만족과 기쁨을 얻는 학생이 의학교육과정을 거치면서 보상신호 제공과 관련한 뇌의 능력을 활요할 가능성이 더 높으며, 따라서 학습 프로세스도 더 촉진될 것이다. 비슷하게, 이러한 생물학적 기능을 더 잘 활용하는 교육과정이나 교수자들이 드문드문 존재하는 보상에 대한 고부담의 기회에만 의존하는 경우(rely only on sparsely distributed and high-stakes opportunities for reward)보다 더 성공적일 것이다.

The students who derive joy and satisfaction from the more immediate goals of understanding as they proceed through their medical education may have a greater chance of using the brain’s capacity to provide reward signals on an ongoing basis, thus effectively facilitating their learning process. Likewise, the curricula and instructors that provide a venue and process to tap into this biologic function may be more successful than those that rely only on sparsely distributed and high-stakes opportunities for reward.

시각화

Visualization

시각화는 외과의사나 운동선수에게는 잘 알려진 프로세스이다.

Visualization is a process well known to surgeons51 and athletes,52,53

학습자가 성공적으로 시각화 테크닉을 활용하여 학습을 강화할 수 있는지 여부는 학습자의 경험 수준에 달려 있다. 예컨대, 연습이나 경험의 양이 심리연습 혹은 시각화를 통해 얻을 수 있는 (수행능력)향상의 정도와 관련되어 있다. 신규 학습자는 상대적으로 지식이나 전문성이 떨어지고, 이것은 제약 요인으로 작용할 수 있다. 따라서 시각화와 같은 학습전략은 교육프로세스의 후반단계에서 더 효과적일 것이다. 즉, 어떤 procedure를 관측하거나 참여해본 다음에 하는 것이 낫다.

The ability of a learner to successfully employ visualization techniques to enhance learning may depend on the degree of experience of the learner. For example, the amount of practice or experience can affect the degree of improved motor performance gained through mental practice and visualization.60 The level of knowledge and expertise of the relatively new learner in a given field (e.g., first- year medical student) may be a limiting factor, and such strategies as visualization may be more effective in later stages of the education process—for example, after having witnessed and participated in procedures.

실제로, 의학교육은 최근 수십년간 이 방향으로 움직여왔다.

Indeed, medical education has moved in this direction over recent decades

의학에서는 '선생으로서의 학생(가르치는 학생)'의 전통을 예전부터 존중해왔다. 의학교육 프로세스에서 능동적인 학습기회를 생성하는 전략에는 다음과 같은 것이 있다.

Medicine has long cherished the tradition of the student as teacher. Throughout the medical education process, strategies that create active learning opportunities include

• 선생의 역할을 해볼 수 있는 기회 learners’ having multiple opportunities to assume the role of teacher,

• 교사-학생간 상호작용과 질문을 장려하는 학습장소venue learning venues that encourage interaction/questioning between learners and teachers,

• 정보의 탐색에 대해 개인이 책임이 있음을 강조 learners’ taking personal responsibility for discovery of information, and

• 학습자에게 피드백 feedback to learners of the information they have assembled and its validity.

스트레스

Stress

너무 높은 스트레스는 반대 결과를 낮는다. 소규모의, 상호작용이 풍부한 교육형태가 스트레스를 규칙적으로 시스템에 도입하는 현명한 방법이다.

However, particularly high levels of stress can have opposite effects.64 The small, interactive teaching format may be judiciously employed to moderately engage the stress system on a more regular basis.

피로

Fatigue

휴식과 수면이 기억을 강화시키고, 작업기억으로부터 장기, 안정적 형태로 만든다는 근거가 많이 있다.

There is increasing evidence of the importance of rest/sleep for the consolidation of memories and the enhancement of their representations from working memory stages into a long- term stable form.65

더 나아가서 이 연구결과들은 많은 집중력을 요하는 문제해결 세션이나 세밀한 양적 추론 스킬이 필요한 그룹 활동 사이에는 적절한 휴식기downtime을 갖는 것이 중요하다는 것을 강조한다.

Moreover, this research suggests that it is important to have appropriate downtime between intense problem-solving sessions or group venues where detailed quantitative reasoning skills are required.

멀티테스킹

Multitasking

운전을 하는 것과 같은 신체활동이 cognitive distraction을 일으키는 것은 명확하다. 그러나 운전 중 핸드폰을 조작하는 것 같은 신체활동 뿐 아니라, 대화를 하는 것과 같은 인지적 경쟁cognitive competition도 수행능력을 저하시킨다.

The data are clear on the subject of cognitive distractions while performing physical activities like driving a car: It’s not just the physical act of managing a cell phone that diminishes driving performance but also the cognitive competition between attending to the conversation and the driving that further degrades performance.67

다양한 (학습스타일에 따라) 개개인의 신경 반응도 다양하고, 이것이 모든 학습자를 위하여 다양한 학습스타일을 인정해야 하는 이유이다. 이를 통해서..

The neural responses of these different individuals also show variability, and that is the rationale for embracing multiple learning styles to provide opportunities for all learners

• 효과적으로 목표를 달성하고 to be most effectively reached,

• 긍정적 피드백과 성공의 기회를 주고 to provide opportunities for positive feedback and successes, and

• 어떤 식의 접근법에서도 뛰어난 모습을 보이는 학생에게조차 다양한 수렴적 전략multimodal convergent 으로 정보를 강화할 수 있다.  to reinforce information with multimodal convergent strategies, even for those who excel equally with all approaches.

같은 정보를 다양한 감각기관을 활용하여 다시 접하는 것은 학습 프로세스를 강화한다.

Multiple teaching approaches addressing the same information using different sensory processes are likely to enhance the learning process,

이제 어떻게 해야 하는가?

Where Do We Go From Here?

교육자들이 학생들에게 왜 특정 접근법을 활용하는지를 설명해주면, 학생들은 그것을 이해하고, 그 접근법을 받아들여서 상호존중관계를 쌓아나갈 수 있을 것이다. 이러한 관계는 학습강화의 보상 시스템으로 작용할 수 있다. 학생이 '의학을 배우는 것으로부터 즐거움을 얻을 수 있는 능력' 뿐 아니라 '교사가 선택한 교육프로세스의 rationale를 이해하는 학생의 지적능력'에도 호소함으로써 학생은 진정으로 동기부여될 수 있다.

If educators take the time to explain to students why certain teaching approaches will be used, the students may understand and accept the approaches and develop a mutually respectful relationship with their instructors. That relationship may also serve as a reward systemfor learning enhancement. By appealing not only to students’ capacity to derive pleasure from learning about medicine but also to their intellectual capacity for understanding the rationale for the educational process selected by the instructor (based on various principles, including those derived from the neurobiology principles of learning), real motivation can be engendered.

의학교육자를 위한 권고

Recommendations for Medical Educators

• Apply the current knowledge of the neurobiology of learning to the lifelong education of health care professionals.

• Base faculty development practices on current knowledge of the neurobiology of learning.

• Share with the learner the underlying neurobiological principles that shape the pedagogy of the learning experience.

• Establish a toolbox of evidence-based practices for medical education that applies current knowledge of the neurobiology of learning.

• Develop a shared research agenda between neurobiologists and medical educators.

What can medical education learn from the neurobiology of learning?

바이오인포메틱스: 의사가 알아야 할 것, 의사가 배우는 방법의 변화(Acad Med, 2011)

Biomedical Informatics: Changing What Physicians Need to Know and How They Learn (Acad Med, 2011)

William W. Stead, MD, John R. Searle, PhD, Henry E. Fessler, MD,

Jack W. Smith, MD, PhD, and Edward H. Shortliffe, MD, PhD

바이오인포메틱스는 다학제간interdisciplinary과학의 한 분야로서 과학적 탐구/문제해결/의사결정/의사소통을 위하여 자료/정보/지식을 효과적으로 활용하는 것을 목적으로 한다. 비록 이 분야가 1950년대부터 시작되긴 했지만, 의과대학에서는 자주 다뤄지지 않았는데, 비교적 최근까지 의과대학 학장들은 공학이나 컴퓨터과학 분야에서 주로 다루는 것이라고 생각했기 때문이다.

Biomedical informatics is the interdisciplinary scientific field that studies and pursues the effective use of data, information, and knowledge for scientific inquiry, problemsolving, decision making, and communication. Although the field dates to the 1950s,1 until relatively recently because deans of medical schools saw it as a disciplinary priority of other schools such as engineering or computer science.

생의학의 복잡성이 크게 늘어나면서 의학적 의사결정의 패러다임이 '한 사람의 두뇌'에서 'systems of brains의 협력적 힘'으로 옮겨가기 시작했다

At this juncture, the explosive growth of biomedical complexity calls for a shift in the paradigm of medical decision making—from a focus on the power of an individual brain to the collective power of systems of brains.

한 사람의 두뇌에서 두뇌의 시스템으로

Shifting the Paradigm From Individual Brains to Systems of Brains

오늘날 의학교육 프로세스와 교육과정은 개개인을 전문가로 발달하게 한다.

Today’s medical education processes and curricula lead to the development of individual experts.

"개인 전문가individual expertise"에 의존하는 의료행위는 자율성/자신감/다양한 현실에서의 우아한 적응 등을 발생시킨engender다

This practice of depending on individual expertise engenders autonomy, self-confidence, and gracious acceptance of variability in practice.3

그러나 한 사람의 두뇌가 가진 인지적 용량은 한 차례의 의사결정 당 다섯 세트의 팩트만을 관련지을 수 있을 뿐이고, 이는 전문성-기반 의료의 한계로 작용한다. 하나의 돌연변이와 하나의 질병간의 관계만을 보여주는 single genetic test와 달리, full genetic sequence는 개인의 질병에 대한 취약성과 어떤 사람이 특정 진단을 받을 가능성을 변화시킬 수 있는 다수의 low-power association 정보를 제공한다.

However, the cognitive capacity of individual brains, which can correlate only about five sets of facts in a single decision,4 limits expert-based medicine. Unlike single genetics tests, which strongly associate one mutation with one disease phenotype, the full genetic sequence will provide many low- power associations that in combination change prior probabilities about both an individual’s susceptibility to disease states and the likelihood of that individual carrying a specific diagnosis. Specialization is not a viable approach to managing this complexity.

'전문성-기반 의료Expert-based practice'의 초점은 개인의 능력에서 시스템-기반 진료로 옮겨갈 것이며, 이는 시스템의 능력에 초점을 둔다는 것을 의미한다. 여러 사람으로 이뤄진 팀과, 잘 정의된 프로세스와 IT가 합해져서 하나의 시스템으로서 결과를 도출할 것이다. 무엇인가를 빼먹거나 실수가 있다면 이 역시 정보로서 제공되어 시스템의 향상 방향을 알려줄 것이다. 학문-중심 교육과정은 환자돌봄을 위한 systems approach를 활용하는 학습 프로세스와 align되는 방향으로 바뀔 것이다. 성공적으로 도입된다면, 다학제간팀interdisciplinary team이 자신의 일을 하는 동안 학습은 필수불가결하게 이뤄질 것이다. 팀은 개인과 팀의 역량을 평가할 것이며, 학습모듈, 전문가 원격접속, 시뮬레이션 등을 활용하여 부족한 부분을 매워갈 것이다. 성과 데이터는 곧바로 역량평가와 개선점 탐색에 활용될 것이다. 인포메틱스 토대가 의료와 의학교육을 모두 지원해줄 것이다.

Expert-based practice, with its focus on the individual’s performance, will shift to system- supported practice, with a focus on the system’s performance. Teams of people, well-defined processes, and IT will work as a system to produce the desired result. Each omission or error will provide data to guide iterative improvement of the system.7 Discipline-specific curricula will shift to align with a learning process that utilizes the systems approach to care.8 If successful, learning will become an unavoidable outcome as interdisciplinary teams go about their work. The teams will assess individual and team competency against upcoming work, and they will be able to use learning modules, remote access to experts, and simulation to close gaps. Outcomes data will be readily available to assess competency and identify areas for improvement. An informatics foundation will support both medical practice and medical education.7,8

인포메틱스 환경에서의 학슴, 환자돌봄, 연구

Learning, Clinical Care, and Research in Informatics-Rich Environments

초창기의 컴퓨터-기반 학습환경은 단순히 기존의 교수법을 따라하는 것에 불과했으며, 테크놀로지 없이도 가능한 교육에 테크놀로지를 활용하여 동일한 것을 한 것에 불과했다.

Early computer-based learning environments merely mimicked established teaching methods, using technology to perform the same teaching tasks that had been possible without it;

더 근래의 접근법은 현대의 인포메틱스와 학습을 도입하였다. Beaumie and Reeves는..

More recent approaches have attempted to couple modern informatics and learning. Beaumie and Reeves9 propose that a 

학습자가 (학습)도구는 낮은 수준의 과제(자료 보여주기, 의사결정 옵션 제공하기)를 수행하는 동안 높은 수준의 인지활동(방향 결정하기, 의사결정, 평가결과를 기반으로 접근법을 바꾸는 것)을 하는 것

learner performs higher-level cognitive activities (e.g., executing directions, making decisions, and/or changing approach based on assessment results), while the tool performs lower-level tasks (e.g., visually representing data or providing decision options).

인포메틱스는 교육과정과 학습(과정)을 서포트 할 수 있다. Denny 등은 교육과정 내용을 검색할 수 있는 웹-기반 리소스를 묘사한 바 있다. 교수와 학생은 리소스로부터 교육프로그램이나 학년의 경계를 넘나들며 어떤 개념에 대해서 검색할 수 있으며 가상과목virtual course처럼 관련된 자료만 볼 수도 있다.

Informatics can support curricula and learning more broadly as well. Denny and colleagues describe a Web-based resource to search curricular content.10 Faculty and students may then search the resource to find concepts across programand school year boundaries, and they can browse the related material as a virtual course.10

어떤 사람들은 EHR을 의료행위와 의학교육을 연결시켜주는 용도로 제안하기도 했다. Stead는 EHR과 임상인포메틱스 도구를 활용하여 학습을 서포트하는 네 단계 프레임워크를 제안하였다.

Others, too, have suggested uses for the EHR to link medical practice and medical education. Stead proposes a framework of four tiers through which the EHR and related clinical informatics tools could support learning.13

• 리소스 소모를 측정하고 그룹 내intragroup 차이를 identify 한다.
  The processes that both measure variation in resource consumption (e.g., length of inpatient stays, tests performed, medications used) and identify intragroup variation in practice provide the framework’s foundation.

• EHR자료를 활용하여 인지적 에너지를 확보하여 정보의 통합synthesis에 초점을 둔다. 인포메틱스는 의사가 자신의 의료행위와 환자outcome을 연결시킬 수 있게 도와주며, open-loop practice에 피드백을 줌으로써 closed-loop 으로 만들어준다.
  In the next tier, physicians use data from the EHR to free their cognitive energy to focus on synthesis; the informatics allows them to tie their own practices to their own patient outcomes, converting their open-loop practice into a closed loop with feedback.14

• 예상하지 못한 상황의 탐지와, 의사결정지원시스템의 활용가능성(경보, 환자-특이적 변화, 근거 link)
  The capacity to detect unexpected events and the availability of decision-support systems (with alerts and reminders, patient-specific information about changes in practice, and links to evidence) together make up the third tier.

• EHR과 바이오뱅크의 추출물extract을 통해서 상관관계를 찾고 가설을 설정함
  In the fourth tier, extracts from the EHR and bio-banks combine to support correlation and hypothesis generation.

다른 요약

• 의료행위의 variation을 측정 That is, first, measure practice variation;

• 개개인에게 맞춘 피드백을 제공 second, provide individual feedback on practice and outcomes;

• 의사의 손바닥fingertips에 지식과 정보를 제공하여 진료 향상 third, improve individual practice by placing knowledge and information at physicians’ fingertips; and

• Care의 향상을 위해 검증가능한 가설을 제공하여 의학을 진보시킴 finally, support advancement of medical science by suggesting testable hypotheses to improve care.

일부에서는 이미 EHR이 광범위하게 활용되고 있다. Veterans Health Administration (VHA) 에서는 EHR을 활용해서 학습을 더 빠르게 하려는 목적으로 national laboratory를 제공하고 있다. VHA는 시스템 차원의 장기적 자료를 활용하여 care management의 효과를 정량화하고 site-to-site varation이 physician-to-physician variation보다 더 크다는 것을 보여주었다. 더 나아가서 EHR은 시판 후 약제의 pharmacovigilence를 도와주어서 시판 전에 알지 못했던 약물유해사건을 감지할 수 있게 도와준다. EHR은 임상가설을 생성해주기도 한다. Hanauer 등은 유전자-매핑 소프트웨어를 활용하여 자연어free-text 임상문제 기술서로부터 잠재적 연관성을 찾기도 하였다.

Some have already begun to use the EHR extensively. The Veterans Health Administration (VHA) has provided a national laboratory on the use of EHRs to accelerate learning. The VHA has used system-wide, longitudinal data to quantify the impact of care management and to show that site-to-site variation is more significant than physician-to- physician variation within sites.15 Further, EHRs have the potential to support comprehensive postmarket pharmacovigilence and to accelerate detection of unrecognized adverse drug events.16 EHRs also have the potential to generate clinical hypotheses. Hanauer and colleagues demonstrated the feasibility of using gene-mapping software to identify potential associations among free-text clinical problem statements in their EHR.17

인포메틱스 환경의 장점과 단점

Beneficial and Deleterious Effects of Informatics-Rich Environments

이 많은 것들이 EHR로의 변화를 겪어본 사람에게는 친숙할 것이다.

Many of these are familiar to those who have experienced a transition to EHRs.

(학생들이) 주치의의 source data에 직접 접근이 가능해지면 정보를 통합하기 전에 비판적으로 생각해야 할 필요성이 줄어들고, 노트를 copy and paste하는 능력 등이 줄어드는데, 이런 것들은 학생들이 무엇을 어떻게 기록으로 남길지 결정해야 할 필요성이 줄어들게 만들고, 의료기록에서 narrative를 위협한다.

Some potential problems include attendings’ direct access to source data, which reduces the need for students to think critically beforehand to synthesize and present the data, and the abilities to copy and paste notes and to access results instantaneously, both of which, first, reduce the need for students to decide what and how to document and, second, threaten the narrative in the medical record.

문제는 테크놀로지 그 자체가 아니라 그것을 활용하는 방식이다.

We believe the problems lie not in the technology per se, but in its application.

Patel 등은 인지와 의사결정지원 사이의 관계를 살펴보았다. IT가 단순히 의사결정 프로세스를 향상시킬 뿐만 아니라, 인지용량에 지속되는 영향을 주어서 의사결정 프로세스 자체를 완전히 바꾸어놓기도 한다. Eddy and Gigerenzer의 연구결과를 바탕으로 의사에게 자료를 제시하는 구조가 의사의 판단에 영향을 줌을 보여주었다. 즉, 자료가 제시되거나 시각화되는 방식이 의사가 그 자료를 해석하는 방식에 영향을 준다는 것이며, 그 자료에 기반하여 이뤄는 당장의 의사결정 뿐 아니라 비슷한 유형의 자료에 의해서 내려지는 미래의 의사결정도 영향을 받게 된다.

Patel and colleagues review the relationship between cognition and decision support. They show that IT does not merely support or enhance the decision process, but fundamentally transforms it, having an enduring effect on cognitive capacity.21 They draw on work by Eddy22 and Gigerenzer22 to show that the very structure of the presentation of data to a physician affects the physician’s judgment. That is, the way data are shown or visualized strongly influences the way physicians interpret the data, the decisions they make based on the data, and even future decisions they will make based on similar data they later encounter.

미래 의사를 위한 인포메틱스 역량

Informatics Competencies for Future Health Professionals

2003년 IOM의 HPES에서는 의료전문직이 갖춰야 할 핵심 역량 영역 중 하나로 인포메틱스 활용을 꼽았다.

In 2003 the Institute of Medicine’s Health Professions Education Summit identified utilizing informatics as one of the five domains of core competency for health care professionals.24

EHR을 이상적으로 활용하기 위해서는 특별한 능력을 필요로 한다.

The optimal use of the EHR at the bedside does require some special skills,

의사들은 확실히 이러한 능력을 습득할 수 있다. Morrow 등은 학생을 두 그룹으로 무작위로 구분하고 한 그룹만 EHR-특이적 커뮤니케이션 스킬을 훈련하였는데, intervention group이 10개의 EHR-특이적 스킬 중 6개에서 더 나은 수행능력을 보여주었다.

but physicians can certainly learn these. Morrow and colleagues 25 The researchersthen randomized students into two groups: one group received training in EHR-specific communication skills, and the other did not. The intervention group performed better on 6 of 10 EHR-specific skills

2008년 AMIA와 AAHC는 공통의 의사결정역량을 개발하였다.

In 2008, the American Medical Informatics Association and the Association of Academic Health Centers convened representatives of 14 health professions in a DesignShop at the Vanderbilt Center for Better Health to develop a common informatics competency framework.26

교수개발을 위한 단계들

Broad Steps for Faculty Development

computational techniques의 강점과 약점을 충분히 이해함으로써 의사들이 인포메틱스 도구가 제시한 결과를 언제 수용하고, 언제 기각해야 하는가를 결정하는데 도움이 될 수 있다.

Sufficient understanding of the strength and weaknesses of the computational techniques will help physicians decide when to accept, and when to override, the results of their informatics tools.

의과대학의 투자와 지원이 인포메틱스-강화 의료의 진화를 더 빠르게 만들 수 있다. 다음의 네 가지 큰 단계를 제안한다.

Investment and support by medical schools can hasten the evolution to informatics-enhanced patient care and learning. We suggest the following four broad steps:

(1) 바이오메디컬 인포메틱스를 위한 학문단위academic unit을 만들라
create academic units in biomedical informatics;

(2) AHC의 IT인프라를 연구실testing laboratories로 개조adapt하라 adapt the IT infrastructure of academic health centers (AHCs) into testing laboratories;

(3) 의학교육자들이 바이오메디컬 인포메틱스의 활용모델을 만들 수 있게 충분히 설명해주라 introduce medical educators to biomedical informatics sufficiently for them to model its use; and

(4) AHC교수들이 바이오메디컬 인포메틱스에 의해서 가능해진 systems approach에 기반한 헬스케어로의 전환을 이끌도록 하라
retrain AHC faculty to lead the transformation of health care based on a new systems approach enabled by biomedical informatics.

1. 새로운 학문단위

Create academic units in biomedical informatics that have a seat at both the academic and operational tables.

A critical mass of faculty who understand biomedical informatics can provide the nucleus to teach noninformatics faculty and students how to use informatics techniques and tools in their work.

2. IT인프라

Adapt the IT infrastructure of AHCs into testing laboratories to evaluate and utilize emerging biomedical informatics techniques for data aggregation, systems analysis, and visualization support.

AHCs with informatics units can supplement simple automation by using

• computational techniques such as connectivity, social networks that connect people to one another and to systems;

• statistical decision support, in which multiple weak signals contribute to robust answers; and

• data mining, through which relationships are discovered among data from diverse highly dimensional data sets.

These approaches allow the clinical information system infrastructure to serve as a laboratory where physicians, physician educators, and physicians-in-training may evaluate and apply informatics “interventions.”29

3. 의학교육자
Introduce medical educators to biomedical informatics sufficiently for them to model its clinical and research uses, to modernize curricula appropriately, and to evaluate trainees and teaching methods.

This shift changes curricular priorities as well as learning and evaluation strategies. One strategy, for example, is using clinical outcomes to measure the effectiveness of a learning intervention.

4. 교수
Retrain faculty in AHCs to lead the transformation to health care that incorporates systems approaches enabled by biomedical informatics.

 The first step is to build awareness within the leadership and faculty of academic medicine that the change is unavoidable. Like many changes, this one offers opportunities— Growing dissatisfaction with current roles, under the dual pressures of cognitive overload and payment reform, may ignite the burning platform and motivate the leap needed to reach a sustainable next generation model for the profession.

26 Designing the informatics component of an IOMchasmhealth professions core competencies curriculum. Vanderbilt Center for Better Health. American Medical Informatics Association (AMIA) Design Session, AMIA Academic Forum, and American College of Medical Informatics. Vanderbilt University, Nashville, TN, 2008. Available at: https://www.mc.vanderbilt.edu/ vcbh/ds/081001amia/index.html. User id: 081001_amia, Password: grant.

Acad Med. 2011 Apr;86(4):429-34. doi: 10.1097/ACM.0b013e3181f41e8c.

Biomedical informatics: changing what physicians need to know and how they learn.

변화의 도구로서의 교수개발: 전문직업성 교육에 관한 사례연구(Acad Med, 2007)

Faculty Development as an Instrument of Change: A Case Study on Teaching Professionalism

Yvonne Steinert, PhD, Richard L. Cruess, MD, Sylvia R. Cruess, MD, J. Donald Boudreau, MD, and Abraham Fuks, MD

"전문직교육의 어려운 점은 어떻게 분석적사고/능숙한행동/현명한판단의 복잡한 조화를 가르치느냐는 것이다"

The challenge for professional education is how to teach the complex ensemble of analytic thinking, skillful practice, and wise judgment upon which each profession rests. 

—WilliamM. Sullivan, Work and Integrity: The Crisis and Promise of Professionalismin America, 2005

어떤 대규모 조직에서든 변화를 일으키는 것은 어려우며 의대도 마찬가지다.

Effecting change in any large organization is difficult, and faculties of medicine (i.e., medical schools) are no exception.

일부 관측자들은 '본질적으로 보수적인', '현재 상태에 매몰된' 등의 용어로 의료전문직에서 변화를 일으키는 것의 어려움에 대해 코멘트한 바 있다. 이들을 지지원하기 위하여 어떤 교수들은 외부의 컨설턴트를 고용해서 변화 프로세스에 공식적 관리테크닉을 도입하고자 했다.

Several observers have commented on the difficulty of implementing change within the medical profession and its institutions, which have been described as being inherently conservative and devoted to the status quo.1–4 To assist them, some faculties of medicine have used outside consultants to bring formalized management techniques into the change process.5,6

McGill 의과대학은 변화의 8단계 모델이 유용하다고 보았다.

We at the Faculty of Medicine at McGill University have found it useful to apply an eight-stage model for implementing change,7,8

교수개발은 다음과 같이 정의.

Faculty development has been defined as

• that broad range of activities that institutions use to renew or assist faculty in their roles.11
• That is, faculty development is a planned program, or set of programs, designed to prepare institutions and faculty members for their various roles.12
• 점차 포괄적인 교수개발 프로그램이란 개인의 발전 뿐 아니라 점점 더 복잡해지는 조직(의 발전)에 대해서도 다뤄야 한다고 인정받고 있다.
  For some years, it has been recognized that comprehensive faculty development programs cannot focus solely on individual improvement; they must also address the increasingly complex institutions in which teaching and learning occur.13,14

프로페셔널리즘의 중요성

The Importance of Professionalism

지난 수십년간 의사와 환자 사이에 상당한 불편함이 있었다. 의사들은 그들의 환자에 대한 태도와 의료기술을 강조하는 것에서 '하지 말아야 할 것을 한 죄와 해야 할 것을 하지 않은 죄'에 모두 책임이 있는 것처럼 느꼈다. 동시에 환자들은 근대과학에 기반한 의료에 예전 의사들이 보여주던 compassion을 더한 진료를 원했다. 환자는 의사들로부터 자신들의 자율성/책무성/투명성을 모두 요구했고, 모든것보다도 '유능한 치유자'로서의 봉사service를 원했다.

The past few decades have witnessed the development of a profound sense of unease amongst physicians and patients. Physicians feel that they are being “held to account for sins of both commission and omission,”15 for their attitudes towards patients and for their emphasis on medical technology. At the same time, patients express a strong desire for care that is based on modern scientific medicine combined with the compassion of the physician of yesteryear. They wish respect for their own autonomy, accountability and transparency from their physicians, and, above all, the services of a competent healer.15

의료계는 이에 화답했다.

The medical profession has responded.18

이 문제를 해결하기 위해서 McGill의과대학은 일찍부터 프로페셔널리즘을 가르치는 것은 하나의 과목이나 포커스가 좁고 목표가 제한적인 특정 교육과정활동만으로는 해결되지 못할 것임을 인지하였다.

In addressing these issues, McGill’s Faculty of Medicine realized early on that the teaching of professionalism could not depend solely on the establishment of a single course or selected curricular activities with a narrow focus or limited objective.

프로페셔널리즘 교수-학습

Teaching and Learning Professionalism

프로페셔널리즘을 효과적으로 가르치고 학생들에게 내면화하기 위한 몇 가지 접근법이 있었다. 또한 프로페셔널리즘을 명시적으로 가릋야 한다고 강조한 사람들도 있었다. 이 때 조작적 정의를 사용할 수도 있고, 특성이나 성격의 목록으로 개념을 개요적으로 서술하기도 했다. 어떤 사람들은 프로페셔널리즘 교육이 '도덕적 노력moral endeavor''로서 접근해야 한다고 하면서, 이타성과 봉사정신을 강조했다. 우리와 다른 사람들은 두 가지 접근법이 모두 필수적이라고 생각했다. 인지적 기반을 반드시 정의해야 하며, 이것을 의사들이 프로페셔널리즘의 본질을 이해하고, 의료의 사회적 계약과 무슨 관계인지 알아야 하고, 프로페셔널리즘이 생존하려면 충족되어야 하는 의무가 무엇인지를 이해하게끔 소통해야 한다고 생각했다. 추가적으로, 정기적regular basis으로 '자기성찰'과 'mindfulness'를 촉진하기 위하여 경험학습의 기회가 제공되어야 함, 이를 통해 프로페셔널리즘이 단순히 이론이나 동떨어진marginal개념으로 남게 하지 말아야 한다고 보았다. 따라서 의학교육에서는 경험을 쌓고/성찰하고/프로페셔널리즘의 개념과 원칙을 습득하기 위한 다수의, 단계적 접근법을 제공해야 했다.

The literature indicates several approaches that must be considered if professionalism is to be taught effectively and internalized by students. There are those who have emphasized that professionalism needs to be taught explicitly, using either operational definitions or outlining the concept as a list of traits or characteristics.19,20,22 Others have stated that the teaching of professionalism should be approached as a moral endeavor, emphasizing altruism and service.29,30 We, and others,24,35,36 believe strongly that both approaches are essential. The cognitive base must be defined and communicated so that physicians understand the nature of professionalism, its relation to medicine’s social contract, and the obligations that must be met if professionalism is to survive. In addition, opportunities for experiential learning must be provided on a regular basis to promote self-reflection37 and “mindfulness,”23 so that professionalism will not remain a theoretical or marginal concept. Professional identity arises from a combination of experience and informed reflection on experience.38 Therefore, a major objective of medical education should be to provide multiple, stage- appropriate opportunities for gaining experience in, and reflecting on, the concepts and principles of professionalism.25,29,30

전문직은 동료간의 협력collegiality을 공통의 목표를 향한 합의를 도출하고, 그들간의 추종compliance를 장려하기 위한 수단으로 사용한다. 존경받는 롤모델로서 동료가 주는 압박은 강력한 수단이다. 반대로 합당한 기준을 충족시키지 못하는 롤모델의 부정적인 효과도 강력하다. 롤모델들이 그들이 보여줘야 하는 역할과 가치관에 대해서 명확히 이해했을 때에야 롤모델이 효과적인 수단이 될 수 있다. 우리에게, 이것은 프로페셔널리즘 교수학습을 촉진기 위한 FDP를 설계하고 도입하기 위해 가장 설득력있는 주장이었다. 추가적으로 우리는 교수들의 자기성찰을 촉진하고 프로페셔널리즘이 중요하다는 강력한 메시지를 던짐으로서 공식 교육과정과 잠재 교육과정에 모두 영향을 주고 싶었다.

Professions use collegiality as a means of obtaining agreement on common goals and encouraging compliance with them.39 The peer pressure of respected role models remains an enormously powerful tool. Conversely, the destructive effects of role models who fail to meet acceptable standards can be equally strong.29,30,40 To be effective, it seems axiomatic that role models must understand and be able to articulate the roles and values that they are expected to demonstrate. To us, this was the most cogent argument for creating and implementing a faculty development program designed to promote the teaching and evaluation of professionalism. In addition, we hoped that it would positively influence both the informal and hidden curricula9,10 by promoting self-reflection in faculty members and sending a strong message that professionalism is important.

프로페셔널리즘에 대한 인식은 거의 없었고, 매우 소수의 교수들만이 교육 프로그램에 참여 가능한 수준이었다. 따라서 교수들의 지지buy-in을 위해서는 포괄적이고 체계적인 교수개발 이니셔티브가 필요했다. 교육의 목표와 내용에 대한 컨센서스를 쌓고, 교수들이 프로페셔널리즘을 더 효과적으로 가르치고 평가할 수 있도록 훈련해야 했다.

there was little faculty awareness of professionalism, and few faculty members were knowledgeable enough to participate in an expanded teaching program. It was therefore decided that a comprehensive and systematic faculty development initiative was needed to promote faculty “buy-in,” to develop consensus on educational goals and content, and to train faculty members to teach and evaluate professionalismmore effectively.

'변화주도'의 사례로서의 교수개발

Faculty Development as an Example of “Leading Change”

우리가 비록 FDP를 계획하는데 있어서 Kotter의 모델을 사용한 것은 아니나, 우리는 곧 이 모델의 단계를 따르고 있다는 것을 인식했다.

Although we did not use the Kotter model in planning this faculty development program, we soon realized that we had followed the steps recommended by Kotter for transforming organizations.8

긴박함 인식

Establish a sense of urgency

Kotter는 긴박함을 인식하게 하는 것이 변화에 필요한 협조cooperation을 얻는데 매우 중요하다고 보았는데, 왜냐하면 현 상태에 만족하는 수준이 높을수록 목표를 달성하기 위한 변화노력이 실패할 가능성이 높기 때문이다. 더 나아가서 긴박함에 대한 인식을 높이기 위해서는 현 상태에 만족하게 만드는 요인을 제거하거나 그 효과를 최소화해야 한다. 내부의 system of measurement를 바꾸거나 더 높은 기준을 설정함으로써 후자가 다성될 수 있다.

Kotter states that establishing a sense of urgency is critical to gaining needed cooperation, because transformation efforts fail to achieve their objectives when complacency levels are high.7,8 Moreover, establishing urgency demands that the sources of complacency be removed or their impact minimized; the latter can be achieved by setting higher standards or changing the internal systems of measurement.

McGill의 사례

• In our own setting, and indeed in most medical schools, this sense of urgency was provided by the widespread belief that medicine’s professionalism and professional status were being threatened by contemporary health care systems, whose values are difficult to reconcile with those traditionally associated with medicine.1,4,16,17
• Without question, the actions of licensing and accrediting bodies reinforced the sense of urgency felt by the faculty and provided a potent stimulus for change.
• The recognition of professionalism as an essential competency by the Royal College of Physicians and Surgeons of Canada,45 the American Board of Medical Specialties,46 the Accreditation Council for Graduate Medical Education,47 as well as the support of the Association of American Medical Colleges48 and the American Board of Internal Medicine,49 created a need for timely action on the part of medicine’s educational institutions.
• However, the knowledge, attitudes, and skills to do this effectively were not readily apparent.
• In our own context, this sense of urgency was communicated to our faculty members through the leadership of the faculty of medicine as well as through a series of educational activities sponsored by the faculty development office, starting with medical education rounds in 1997.

강력한 지도연합체 형성

Form a powerful guiding coalition

Kotter 는 "major change를 달성하기는 너무나 어렵기 때문에, 그 프로세스를 지속시키기 위해서는 강력한 힘이 필요하다"라고 했다. 또한 '변화 이니셔티브'를 관장할 팀의 특성을 강조했는데, 여기에는 지위/권력/전문성/신뢰성/리더십(position, power, expertise, credibility, and leadership)이 포함된다.

Kotter eloquently states that “because major change is so difficult to accomplish, a powerful force is required to sustain the process.”8 (p51) He also highlights the key characteristics of a teamthat can direct a change initiative. These characteristics include position, power, expertise, credibility, and leadership.

McGill의 사례

누가

In our own setting, in June 1999, the dean initiated the process of creating a powerful guiding coalition by inviting 25 educational leaders, consisting of the associate deans responsible for undergraduate and postgraduate medical education, members of the faculty development team, key departmental chairs, program directors at the undergraduate and postgraduate levels, and local content experts, to a half-day “think tank.”

무엇을 목표로

The goal of this session was

• to highlight the importance of professionalism,
• to begin to develop consensus among diverse educational leaders, and
• to discuss ways of reaching out to faculty members across the basic science and clinical teaching sites.

무엇을 하였나

To achieve its objectives, the think tank started with

• a brief overview of the core content of professionalism and
• a review of how professionalism was being taught at all levels of the undergraduate curriculum.

결과물

After a lively debate and exchange of ideas,

• consensus on the importance and content of teaching professionalism was reached.
• A plan for a faculty development workshop was also developed.

비전 창조

Create a vision

"비전이란 (왜 사람들이 그 미래를 창조하기 위해 노력해야 하는가에 대한 묵시적/명시적 코멘터리가 더해진) 미래에 대한 그림이다" 더 나아가 비전은 변화의 방향을 명확하게 해주고 사람들에게 동기를 부여해주며 핵심 플레이어key players를 정렬align해준다.

“Vision refers to a picture of the future with some implicit or explicit commentary on why people should strive to create that future.”8 (p68) Moreover, vision clarifies the direction of the change and helps to both motivate and align key players.

McGill의 사례

싱크탱크가 비전을 창조

At McGill, the think tank described above helped to create the vision for teaching and evaluating professionalism.

More importantly, however, an invitational half-day workshop, which grew out of this first session and focused on teaching professionalism, led to the creation of a vision that we could then articulate faculty-wide.

모든 과의 과장과 전공의교육프로그램 디렉터들 워크숍 수행. 워크숍은 세 가지 파트로 구성

In December 1999, the dean invited all department chairs and undergraduate and postgraduate program directors to a half-day workshop designed to examine the working definition of professionalism and its attributes and to determine the strengths and weaknesses of diverse teaching methods. More specifically, the workshop was organized into three parts:

• 프로페셔널리즘의 핵심 내용 the core content of professionalism,
• 참여자들의 관점과 신념 the participants’ personal views and beliefs, and
• 교육 전략 strategies for teaching.44

워크숍의 성과(1)

By the end of this session, we had

• developed a broad agreement regarding the importance of professionalism and its core content,
• discussed ways of implementing the teaching of professionalism in specific departments and sites, and
• developed a plan for a faculty-wide workshop.

워크숍의 성과(2)

We had also

• prepared a cohort of small- group facilitators for future workshops and teaching sessions and
• devised a series of recommendations regarding the teaching of professionalism that were presented to the undergraduate and postgraduate curriculum committees.

이 워크숍의 핵심 메시지: (1)프로페셔널리즘 교육을 명시적으로 해야 한다 (2)롤모델이 중요하다.

The two key messages of this workshop were

(1) the need to make the teaching of professionalism explicit, and

(2) the importance of role modeling.

비전의 소통

Communicate the vision

Kotter 는 "비전의 진정한 힘은 (변화활동에) 관계된 대부분의 사람이 목표와 방향에 대한 공통된 이해를 가지고 있을 때 드러난다"

Kotter states that “the real power of a vision is unleashed only when most of those involved in an activity have a common understanding of its goals and direction.”8 (p85)

McGill의 사례

전체교수대상 워크숍 진행

The vision for teaching and evaluating professionalismat McGill was communicated through the support given by the dean and the associate deans. It was also promulgated by another faculty-wide workshop on teaching professionalism that accommodated 65 health care professionals representing the basic sciences and all major medical specialties. This workshop, which was held in December 2000, was designed

• 프로페셔널리즘의 중요성을 강조하고 to highlight the importance of teaching professionalism and
• (다음을 토대로) 교육을 향상시키기 위함 to improve such teaching by
• transmitting core content,
• discussing effective teaching strategies, and
• developing an action plan for each department.

워크숍의 성과

This workshop resulted in

• increased buy-in among the educational leaders who participated, and it led to the
• development of new content experts and an array of educational resources that could be used for teaching purposes.

비전을 공유하기 위한 추가적인 활동으로 이어졌음

It also led to a number of other activities designed to communicate the vision for change, including

• educational sessions for residents,
• hospital grand rounds,
• departmental workshops, and
• high-profile activities outside McGill such as peer-reviewed publications and presentations at national and international meetings.

다른 사람들이 비전을 따라 행동할 수 있는 권한 부여

Empower others to act on the vision

Kotter 는 다른 사람들이 변화를 가져올 수 있게effect change 하는데 필수적인 요소 다섯가지 중 하나로 '트레이닝 제공provision of training'을 꼽았다.

Kotter specifically identifies the provision of training as one of the five essential ingredients to empower people to effect change.7

McGill의 사례

교수개발이 변화를 위한 주된 vehicle중 하나였음

In our context, faculty development has been one of the major vehicles for empowering others to lead the change initiative.

해당 이슈의 중요성이 널리 퍼짐

Knowledge of the importance of the issues became widely recognized as a result of the think tanks and workshops, during which workable solutions appropriate to McGill’s culture and environment were developed.

워크숍에 다양한 방법 활용

Methods used in the workshops, which included case vignettes, organizing frameworks for matching content to methods, and opportunities for experiential learning and reflection, empowered our educational leaders and colleagues.

교수들이 다음에 대한 합의를 가지게 됨

In many ways, the faculty development program allowed our faculty members to agree on

• the cognitive base of professionalism,
• the attributes and characteristics of the professional, and
• the behaviors to be encouraged among students, residents and faculty.

어떻게 'healing'이라는 개념이 교육 프로그램에 통합될 수 잇는가

It also provided us an opportunity to explore further how healing, a concept that is essential to the medical mandate, could be integrated into our teaching program.19

교수들이 다음을 인식하게 됨

Faculty members came to realize

• 학생들과 cognitive base를 소통해야 한다 that the cognitive base of professionalism and healing must be communicated to students, and
• 다양한 교육법, 평가법이 활용되어야 한다 that diverse teaching and evaluation strategies should be used.

의사의 두 가지 역할(전문직 and 치유자)에 기반한 학부교육과정의 리뉴얼을 위한 비전

This reflection and discussion also led to a vision for renewal of the undergraduate medical curriculum based on the dual roles of the physician: professional and healer

단기 성공의 성취

Generate short-term wins

Kotter 는 단기 성공이 다음에 중요하다고 강조함

Kotter highlights the importance of short-term wins in

• 변화 촉진 promoting change,
• 노력에 대한 강화(더 노력하게끔) providing reinforcement for the efforts taken,
• 비전과 전략의 미세한 조정 helping to fine-tune the vision and strategies implemented, and
• 모멘텀 수립 building momentum.7,8

McGill의 사례

In our context, we experienced the following short-term gains:

프로페셔널리즘 평가로 초점을 옮겨감

Our early efforts to promote the teaching of professionalism also led to the need to focus on the evaluation of professionalism.

• 비록 평가를 하고 있지만 개선되어야 함 Although aspects of professionalism were being assessed routinely on in-training evaluations, improvement was needed.
• 또 다른 싱크탱크 Thus, several years after this change initiative started, we held another think tank, this time on evaluating professionalism. It was clear to us that for teaching to be successful, professionalism would need to be evaluated in a more systematic way.
• 20명의 리더와 내용전문가와 함께 워크숍 Thus, we invited 20 educational leaders and content experts to examine methods of evaluating professionalism and to develop the content and methodology of a workshop in this area. At the time, we

• 전문직으로서의 의사와 치유자로서의 의사의 특성이 통합되어야 함 realized that the attributes of a physician as professional and healer had to be integrated for evaluations to be comprehensive; we therefore
• 정의의 수정 added a definition of healing, including the attributes of the physician as healer, which had been developed and agreed on by a work group on healing (as outlined in List 1 and List 2).

• 워크숍의 결과로 또 다른 전체교수 워크숍의 세부 계획이 나옴 The outcome was a detailed plan for a faculty-wide workshop, called Evaluating the Physician as Healer and Professional, in May 2002.