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1 ORIGINAL ARTICLE Development of Task-Based Learning Outcomes according to Clinical Presentations for Clinical Clerkships HyeRin Roh 1, Byoung Doo Rhee 2, Jong-Tae Lee 3 and Sang Kyun Bae 4 Departments of 1 Medical Education, 2 Internal Medicine, 3 Occupational & Environmental Medicine, and 4 Nuclear Medicine, Inje University College of Medicine, Busan, Korea 임상실습을위한임상표현별직무중심학습성과목표개발 인제대학교의과대학 1 의학교육학교실, 2 내과학교실, 3 예방의학교실, 4 핵의학교실 Purpose: The aim of the study was to introduce our experience of establish task-based learning outcomes for core clinical clerkships. Methods: We first define our educational goal and objectives of the clinical clerkship curriculum according to knowledge, cognitive function and skill, and attitude. We selected clinical presentations and related diseases with expert panels and allocated them to core clinical departments. We classified doctor s tasks into 6 categories: history taking, physical examination, diagnostic plan, therapeutic plan, acute and emergent management, and prevention and patient education. We described learning outcomes by task using behavioral terms. Results: We established goals and objectives for students to achieve clinical competency on a primary care level. We selected 75 clinical presentations and described 377 learning outcomes. Conclusion: Our process can benefit medical schools that offer outcome-based medical education, especially for clinical clerkships. To drive effective clerkships, a supportive system including assessment and faculty development should be implemented. Key Words: Outcome-based education, Clinical competency, Clinical clerkship 임상실습은학생이실제환자를경험하면서의사의역량을습득하는매우중요한단계이다 [1]. 따라서임상실습에서는중요한핵심지식을단순히알고있을뿐만아니라, 해야할일 을제대로할수있고바람직한전문직업적태도를갖추도록교육시켜야한다. 그러나임상실습을마친학생들의역량이실제진료현장에서활용되기에는아직충분치못한실정이다 [2]. 임상실습이잘이루어지지못한원인들로는, 체계적이지못한교육과정, 일차진료수준에적합하지않은교육내용, 학 Received: December 21, 2011 Revised: February 7, 2012 Accepted: February 8, 2012 Corresponding Author: Byoung Doo Rhee Department of Internal Medicine, Inje University College of Medicine, 75 Bokji-ro, Busanjin-gu, Busan , Korea Tel: Fax: bdrhee@hanmail.net Korean J Med Educ 2012 Mar; 24(1): pissn: X eissn: C The Korean Society of Medical Education. All rights reserved. This is an open-access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( creativecommons.org/licenses/by-nc/3.0/), which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited. 31

2 HyeRin Roh, et al : Development of Task-Based Learning Outcomes according to Clinical Presentations for Clinical Clerkships 생에게적절한임무가부여되지않는점등이거론되어왔다 [3]. 이러한원인들을해결하기위한방안으로학습성과 (learning outcomes) 를목표로서명확하게제시하고, 구체적인의사의직무 (task) 를바탕으로필수적인핵심역량을교육하자는제안들이제기되고있다 [4,5,6]. 이에교육과정은의사가자주접하게되거나중요한임상표현 (clinical presentation) 을중심으로의사가해야할바람직한행동을통합적으로가르치는방향으로개편되는추세이다 [7]. 연구자들은 2007년부터임상실습목표를의사의직무중심으로설정하고, 주요임상표현별로구체적인학습성과목표를개발하여왔으며학생수준에적절한질병들을구체적으로제시하고있다. 이에그경험을소개하고자한다. 이연구는핵심과목임상실습교육과정을대상으로하였다. 핵심과목은내과, 외과, 산부인과, 소아청소년과, 정신건강의학과, 응급의학과등총 6과목이다. 1) 임상실습교육목적과목표설정임상교육위원회는 2007 년부터교육목표와관련된여러참고문헌들을조사하면서, 대학창립정신과사명, 교육목적과목표, 의과대학비전과발전계획, 의학과교육목표와졸업역량등을검토하였다. 임상교육위원회는 2008년에시행하였던교육과정외부평가결과와매년시행하고있는의학과교육과정평가설문과자료등도검토하였다. 그외에도동문, 학부모, 지역의료계에시행하였던각종설문조사에서나타난임상실습관련결과들을검토하였다. 이러한자료들을바탕으로임상교육위원회는임상실습교육목적을우선선정하였다. 2) 주요임상표현과필수질환군선정임상교육위원회는학생들이꼭알아야할필수증상, 징후, 검사소견만을주요임상표현으로하기로하였다. 또한주요임상표현을일으키는원인질환중우리나라일차진료수준에서흔히만나는원인또는그결과가위중한원인에한하여 5개질환이내로필수질환군을하기로방침을정하였다. 주요임상표현과필수질환들을파악하기위해한국질병통계, 한국의과대학의학전문대학원장협회의학습목표, 의사국가고시항목, 참고문헌등을참고하였다. 임상교육위원회는우선핵심과목임상실습에서다루어야할우리나라에서흔하고중요한임상표현과질환들을추출한후임상실습책임, 부책임교수들이모두참석하는워크숍에서각기중요도를매기도록하였다. 임상교육위원회는이사항들을매년검토하고개정하는작업을진행하였다. 각임상표현과질환등은현재임상실습교육과정에맞게과목별로다시분류하였다. 3) 학습성과목표작성임상교육위원회는의사의직무를병력청취, 신체진찰, 진단계획, 치료계획, 급성및응급조치, 예방및환자교육등으로분류하였다. 임상실습교육목표를고려하면서, 주요임상표현별로각직무에해당하는학습성과목표를행동용어를사용하여작성하였다. 학습성과목표를작성하는작업은워크숍형태로진행되었고한임상표현당 4명이상의각기다른전공분야의교수가참여하였다. 이후임상교육위원회가다시학습성과목표전체를재검토하여수정하는작업을거쳤다. 이러한과정은매년시행하였다. 임상실습의교육목적은학생들이일차진료수준에서흔히만나는임상표현을해결하기위해필요한지적기능과기술, 태도, 지식을습득하는것으로정하였다. 이교육목적에맞추어지적기능과기술, 태도, 지식각각의영역에해당하는임상실습과정에서의성과목표를정하였다 (Appendix 1). 2011년현재총 75개의주요임상표현을선정하였다 (Table 32 Korean J Med Educ 2012 Mar; 24(1):

3 노혜린외 : 임상실습을위한임상표현별직무중심학습성과목표개발 Table 1. Clinical Presentations of Core Clinical Clerkships Discipline Clinical presentation Discipline Clinical presentation Internal Abdominal distention Obstetrics & Amenorrhea Medicine Abdominal pain Gynecology Dysmenorrhea Acute diarrhea Hypertension, pregnancy Anuria/oliguria Intrapartum care Bleeding tendency/bruising Menopause Cervical lymphadenopathy Menstrual disorders Chest pain Pregnancy Constipation Pelvic mass Cough/sputum Pelvic pain Dyslipidemia Vaginal bleeding Dyspepsia Vaginal bleeding, pregnancy Dyspnea Vaginal discharge Dysuria Pediatrics Abdominal pain, child Fatigue Acute diarrhea, infant/child Fever Cough, child Gastrointestinal bleeding Development delay Generalized edema Dyspnea, infant/child Hematuria Failure to thrive, infant/child Hemoptysis Fever, child Hypertension Hematuria, child Incontinence, urine Neonatal jaundice Jaundice Seizure, child Joint pain Skin rash Palpitation Vomiting, infant/child Polyuria Psychiatry Alcohol problems Rhinorrhea Anxiety Smoking cessation Bad news delivery Syncope Domestic violence Vomiting Insomnia Weight loss Memory loss Surgery Abdominal pain, acute Mood change Abscess Substance abuse Hematochezia Thought disturbance Breast lump/pain Emergency Altered mentality Medicine Cardiac arrest Dyspepsia Multiple trauma Groin lump Poisoning Neck mass Shock 1). 과목별로살펴보면, 내과 30개, 외과 7개, 산부인과 12개, 소아청소년과 12개, 정신과 9개, 응급의학과 5개등이다. 2011년현재임상실습에서성취해야할학습성과목표는총 377개로, 내과 184개, 외과 35개, 산부인과 35개, 소아청소년과 60개, 정신과 47개, 응급의학과 13개등이다. 구체적인학 습성과목표의예는 Appendix 2 와같다. 이연구는졸업역량부터시작하여임상실습목표를설정하고이에맞추어각임상표현별로학습성과목표를체계적으로 33

4 HyeRin Roh, et al : Development of Task-Based Learning Outcomes according to Clinical Presentations for Clinical Clerkships 작성하는일련의작업을기술한것이다. 연구자들은교육과정위원회와임상교육위원회등의조직을중심으로전문가집단의총의를이끌어내는과정을자세히소개하였으며이와함께실제개발된임상표현과학습성과목표의예를제시하였다. 이는앞으로직무중심으로학습성과목표를개편하고자하는여러대학에도움이될것으로생각된다. 학생들이의사의직무를임상표현별로학습하는것은미래에학생들이해결해야하는임상상황과연관짓기쉽기때문에기존의강의식암기학습이나도제식학습에비해학생들에게학습에대한동기를부여하는데훨씬더효과적이다 [8]. 직무중심학습은자연스럽게기초의학과의료인문내용을임상의학과함께통합적으로학습하게하는효과도있다 [4]. 직무와관련하여필수질환군과명확한학습성과목표를제시하는것또한학습하여야할핵심을명확하게해주므로, 학생이나교수가시간이나예산을효율적으로사용하여학습하고교육할수있도록해주며 [8], 학생들로하여금학습에대한책임을가지도록한다 [5]. 본연구에서제시한임상표현에는몇가지미비한점들이있다. 첫째, 임상표현을핵심과목으로알려진내과, 외과, 산부인과, 소아과, 정신과, 응급의학과에국한하여조사하였기에, 주요임상표현으로알려진여러증상과징후들이핵심과목과연결되지못하여빠져있다. 예를들면, 손떨림, 붉은눈, 피부발진등은일차진료수준에서핵심적인내용으로참고문헌에서분류되고있으나 [6], 이번연구에서어느특정핵심과에포함시키기어려웠다. 둘째, 복통이나소화불량등일부임상표현은과별로중복되어언급되고있으나, 내과에서는복통, 외과에서는급성복통, 산부인과에서는하복부통증등으로각과에서흥미를가지는부분만강조하여다루고있으며, 이를전체적으로아우르지는못하였다. 이러한문제는임상실습이현재병원의의료시스템에따라과목별로이루어지며, 일차진료를주로담당하고있는가정의학이필수실습과목이아니며, 과목과병원별로교육할수있는환경과시스템이다르기때문인것으로생각한다. 최근여러핵심임상과목을통합하여실습하는장기통합실습 (longitudinal integrated clerkship) 형태가제안되고있다 [9]. Norris et al. [9] 은장기통합실습을통해과목별실습에비해학생들이여러임상문제를가지고있는환자에게 통합적으로접근하고환자의복잡성을더잘이해할수있다고보고하고있다. 따라서장기통합실습을임상실습교육과정에도입하면임상표현을중심으로한교육과정과현병원시스템상의과목별임상실습교육과정과충돌하는문제는많이해소될수있을것으로생각한다. 학습성과목표를설정했다는것만으로임상실습이정상화되고잘이루어지기를기대할수는없다. 이러한노력이효과를발휘하기위해서는교수와학생들이직무중심학습성과목표의취지를이해하고실천하도록하는후속조치가뒤따라야한다. 또한실제현장에서이루어지는실습과그에대한학습평가가학습성과목표와일치하여야하며 [4], 임상실습전에이루어지는교육과정에서의학습성과목표도임상실습에서의학습성과목표와잘연결되어야한다. 학생들이임상실습에서학습을적극적으로하는데에는교수의지도와되먹임이중요한바 [1], 교수들의교육역량개발에도관심을기울여야한다. 더불어교육과정을운영하고지원하는행정시스템이나교수업적평가시스템또한학습성과목표에맞추어적절하게갖추어져야할것이다. 모든임상행위에서의학습성과목표를명확히하는일이쉽지는않을것이다. 그러나, 안전하고사회에서수용할수있는좋은의사를만들기위한의과대학의사회적책무성을고려할때학습성과목표를명확히하고자하는노력은반드시필요하다 [10]. We are grateful to large numbers of academic staff who have contributed to the development of the task-based learning outcomes in clinical clerkships at Inje University College of Medicine. We wish to acknowledge particularly the work of the Clinical Education Committee and the Curriculum Committee (including the student members), the administrative and secretarial support of Office of Medicine and the technical support of Unit of Medical Education. None. None. 34 Korean J Med Educ 2012 Mar; 24(1):

5 노혜린외 : 임상실습을위한임상표현별직무중심학습성과목표개발 1. Wimmers PF, Schmidt HG, Splinter TA. Influence of clerkship experiences on clinical competence. Med Educ 2006; 40: Kim YH, Roh HR. Students' perception of their achievement of clinical competency for patient safety. Korean J Med Educ 2007; 19: Lee YM, So YH, Ahn DS, Park SH. Evaluating clinical teaching in medicine. Korean J Med Educ 2002; 14: Harden R, Crosby J, Davis MH, Howie PW, Struthers AD. Task-based learning: the answer to integration and problem-based learning in the clinical years. Med Educ 2000; 34: Harden RM, Crosby JR, Davis MH. AMEE guide no. 14: outcome-based education: part 1-an introduction to outcome-based education. Med Teach 1999; 21: outcome-focused core curriculum. Med Educ 2005; 39: Papa FJ, Harasym PH. Medical curriculum reform in North America, 1765 to the present: a cognitive science perspective. Acad Med 1999; 74: Harden RM, Uudlaw JM, Ker JS, Mitchell HE. AMEE medical education guide no. 7.: task-based learning: an educational strategy for undergraduat postgraduate and continuing medical education, part 1. Med Teach 1996; 18: Norris TE, Schaad DC, DeWitt D, Ogur B, Hunt DD; Consortium of Longitudinal Integrated Clerkships. Longitudinal integrated clerkships for medical students: an innovation adopted by medical schools in Australia, Canada, South Africa, and the United States. Acad Med 2009; 84: Dennick R. Justifications for learning outcomes: more appropriate educational theories. Med Educ 2004; 38: Newble D, Stark P, Bax N, Lawson M. Developing an 35

6 HyeRin Roh, et al : Development of Task-Based Learning Outcomes according to Clinical Presentations for Clinical Clerkships Appendix 1. Clinical Clerkship Goal and Learning Outcome Objectives,,.. [ ] ,. [ ] [ ] 1., (,,,, ). 36 Korean J Med Educ 2012 Mar; 24(1):

7 노혜린외 : 임상실습을위한임상표현별직무중심학습성과목표개발 Appendix 2. Learning Outcome Objective: Vomiting ( ) a) b) / X ( ),,, (, ),, 1. / , a) : 1., 2. b) :

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