REVIEW Review on the administration and effectiveness of team-based learning in medical education Yera Hur 1, A-Ra Cho 2 and Sun Kim 2 1 Faculty Development & Mentoring Center, Konyang University College of Medicine, Daejeon, and 2 Department of Medical Education, The Catholic University of Korea College of Medicine, Seoul, Korea 의학교육에서의팀바탕학습운영과효과성에대한고찰 1 건양대학교의과대학교수개발및멘토링센터, 2 가톨릭대학교의과대학의학교육학과 허예라 1, 조아라 2, 김선 2 Team-based learning (TBL) is an active learning approach. In recent years, medical educators have been increasingly using TBL in their classes. We reviewed the concepts of TBL and discuss examples of international cases. Two types of TBL are administered: classic TBL and adapted TBL. Combining TBL and problem-based learning (PBL) might be a useful strategy for medical schools. TBL is an attainable and efficient educational approach in preparing large classes with regard to PBL. TBL improves student performance, team communication skills, leadership skills, problem solving skills, and cognitive conceptual structures and increases student engagement and satisfaction. This study suggests recommendations for administering TBL effectively in medical education. Key Words: Team-based learning, Problem-based learning, Teaching 서론 지식의전달이중심이었던의학교육은 1985년미국의과대학협회 (American Association of Medical Colleges) 의 General Professional Education of the Physician 보고서가발표되면서성과바탕 (outcome-based) 의학교육으로전환하고, 학생들이졸업후최소한갖추어야할성과를규정하고새로운교육목표를설정하기시작하였다 [1]. 새로운의학교육의목표는세가지로함축해볼수있는데, 쏟아지는의학 지식의홍수속에서진단과치료에필요한정보를수집하고활용할수있는자기주도학습능력, 협력진료환경속효과적인팀워크능력, 기초와임상의학을통합한비평적사고능력의함양이그것이다 [2]. 새로운교육목표는자연스레교육방법의변화를요구하였다. 이러한패러다임의변화를수용하여그동안대부분의교육과정을전통적인강의중심으로운영해오던의과대학들은팀바탕학습 (team-based learning, TBL) 도입을위한논의를활발히진행해오고있으며, 그에따라 TBL 을도입하고있는의과대학의수는점차증가하고있다 [3]. 특히외국의대표적인의학저널검색엔진 PubMed Received: October 27, 2013 Revised: November 9, 2013 Accepted: November 10, 2013 Corresponding Author: Sun Kim Department of Medical Education, The Catholic University of Korea College of Medicine, 222 Banpo-daero, Seocho-gu, Seoul 137-701, Korea Tel: +82.2.2258.7203 Fax: +82.2.2258.7794 email: skim@catholic.ac.kr Korean J Med Educ 2013 Dec; 25(4): 271-277. http://dx.doi.org/10.3946/kjme.2013.25.4.271 pissn: 2005-727X eissn: 2005-7288 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 (http:// 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. 271
Yera Hur, et al : Review on the administration and effectiveness of team-based learning in medical education 에 team-based learning, TBL 키워드를입력하면 2000년 1월부터 2013년 10월까지 70편이상검색되는데이가운데 50편이상이 2010 년이후발표되었으며, MedEdPORTAL 에는 2013년 10월까지 80여개의 TBL 모듈과자원이공유되고있다 [4]. 이러한수치는최근 TBL 에많은관심이집중되고있으며, 이미다양한의학교육분야에서많은경험이축적되고있음을시사해준다. 실제로이미 60여개이상의의학교육기관들이의과대학교육과정 (undergraduate medical education), 전공의교육수련과정 (graduate medical education), 의사의평생교육과정 (continuing medical education) 에 TBL 을도입하고있으며, 성공적인교육경험을바탕으로 TBL 운영과효과성에대한연구결과를지속적으로발표해오고있다 [5,6]. 반면국내에서는 TBL 도입움직임이여전히미비한수준이며연구현황도열악하다. 이는국내에서 TBL 을도입하고있는의과대학의수가매우제한적이라는현실에기인한다. 이러한배경에서이연구는외국의선행연구를바탕으로 TBL 의기본원리와진행단계를살피고, 의학교육에서의 TBL 운영유형과효과성에대한분석을통해국내의의학교육에서 TBL 의도입을위한과제가무엇인지도출해보았다. TBL 기본원리와진행단계 TBL 은 지식의전달 (knowledge transmission) 이아닌 지식의활용 (knowledge application) 에목적을두고있는교 Fig. 1. Team-Based Learning Course Concepts Adapted from Introduction to team-based learning [Internet]. Vancouver, Canada: The University of British Columbia; c2009. Available from: http://cis.apsc.ubc.ca/services/team-based-learning [8]. Fig. 2. Instructional Activity Sequence for Team-Based Learning The diagram represents the team-based learning process. TBL: Team-based learning, irat: Individual readiness assurance test, trat: Team readiness assurance test. Partly adapted from TBL students handout [Internet]. Huntington, USA: Team-Based Learning Collaborative; c2010. Available from: http://www.teambasedlearning.org [9]. 272 Korean J Med Educ 2013 Dec; 25(4): 271-277.
허예라외 : 의학교육에서의팀바탕학습운영과효과성에대한고찰 수법이다 [6]. 이목적을달성하기위해 TBL은두가지변화를시도한다. 첫번째변화는교수와학생의역할변화이다. TBL 에서교수자는 지식의전달자 가아닌교육과정개발자, 수업운영자이자 학습의촉진자 로, 학습자는지식의암기와이해를넘어스스로정보를탐색, 수집하고이를분석하여종합적인사고를바탕으로문제를해결하는 학습의주체자 로역할을하게된다 [7]. 두번째변화는수업구조의변화이다 (Fig. 1)[8]. 일반강의와달리 TBL 의수업구조는팀활동을바탕으로실제의료현장에서부딪힐수있는문제를해결하는과정에수업시간의대부분을할애한다는핵심적인차이가있다. 이러한 TBL 의원리는자기주도학습 (self-directed learning), 준비도확인 (readiness assurance), 적용학습 (application activities), 평가 (assessment) 의단계를거치며실현된다. 수업준비에서부터평가까지의세부진행과정과교수의역할을살펴보면다음과같으며 (Fig. 2) [9], TBL 수업을준비할때 Michaelsen & Seet [10] 이규명한성공적인 TBL 을위한 4가지핵심원칙을고려한다면보다효과적인운영이가능하다 (Fig. 3). TBL 운영유형 선행연구를검토한결과 TBL은크게두가지유형으로운영되고있었다. 연구에따라사용하는용어에는차이가있지만, 이연구에서는의미를명확하게전달하기위하여기본적인 TBL 단계에따라운영하는 classic TBL 과다른교수법과통합운영하는 adapted TBL 로구분하여기술하고자한다. 1. Classic TBL Haidet et al. [6] 은 TBL 기본구조를 1) pre-class preparation, 2) assurance of readiness to apply learned concepts, 3) application of content through group problemsolving activities 로제시하고있다. Classic TBL 유형은 TBL 1세션에 3단계기본구조를모두포함해운영하는형태로, TBL 을도입하고있는대부분의대학이이유형을채택하고있으며일부는교육과정에적합하게수정하여적용하고있었다. Classic TBL 로교육과정을운영하기위해서는계획단계에서부터 TBL 도입여부를사전에결정해새롭게설계하여야한다. 한예로 Fujikura et al. [11] 은 TBL 교수개발워크숍을수료한 20명의교수를투입하고특정교수의개별 Fig. 3. Four Key Principles for Success in Team-Based Learning 273
Yera Hur, et al : Review on the administration and effectiveness of team-based learning in medical education Fig. 4. Team-Based Learning Course Structure at Introduction to Medical Sciences Education at University of Sharjah TBL: Team-based learning, PBL: Problem-based learning, MCQ: Multiple choice question, SAQ: Short answer question. 수업차원이아닌전체교육과정차원에서임상의학 TBL 과정을설계하였으며, 총 15개의 TBL 세션 (3 hours/1 session) 으로운영하여교육내용의연속성을확보하였다. 또한 Masters [12] 도총 11개의 TBL 세션 (2 hours/1 session) 으로의료정보학 과정을운영하여학생들이충분히 TBL을경험할수있도록하였다. 이처럼 TBL 도입을계획했을때가장중요한것은충분한교육시간의확보이다. 이러한맥락에서 Wright State University 의과대학은 1, 2학년기초의학 21개과정과 3, 4학년임상실습 8개과정가운데각각 18개, 5개과정수업의대부분을 TBL로운영하고있어시사하는바가매우크다. 이미선행연구에서도 TBL에서기대되는교육적효과는학생들이지속적으로 TBL 을경험하였을때실현가능함을강조하고있다 [13]. 2. Adapted TBL Adapted TBL 유형의대표적인예는 PBL과의통합운영형태이다. 실제로 Fujikura et al. [11] 은 TBL 이 PBL 을진행할때사전지식이부족하여토론이진행되지않는한계를극복할수있는효과적인촉진전략이라고평가하였으며, Anwar et al. [14] 은 TBL이 PBL 과정중학생들의학업성취를향상시키는데유용한전략이라고보고하였다. 특히 Abdelkhalek et al. [15] 은 PBL 과 TBL을결합한구체적인수업모형을제시 (Fig. 4), TBL 이적은자원으로많은수의학생을충분히준비시키는데효과적이기때문에발견학습 (discovery learning) 을지원하는전략으로활용되기에적합하다고강조하였다. 결론 교육의주체는학생이다 [16]. TBL 은그동안교수중심으로이루어져왔던의학교육에서학생중심교육을실현해주는구조적인전략이란평가를받고있는교수법이다 [17]. 이연구는선행연구를통해 TBL 의기본원리와진행단계를정리하고, TBL 운영유형을살펴보았다. 그결과 TBL은이미다양한의학교육과정에도입되어긍정적인성과를거두고있음을발견할수있었으며, 특히 TBL 을통해기대되는교육적효과는학생들이 TBL을지속적으 274 Korean J Med Educ 2013 Dec; 25(4): 271-277.
허예라외 : 의학교육에서의팀바탕학습운영과효과성에대한고찰 로경험했을때가능함을확인할수있었다. 이는국내의의학교육에 TBL 이효과적으로정착하려면가장먼저 TBL 운영에필요한충분한시간을확보한후기존교육과정을분석하여재설계하는작업이우선되어야함을시사해준다. 만약대학의여건상교육과정의재설계가불가능하거나많은시간을 TBL 에할애하는것에어려움이있다면 PBL 과병합하여별도의시간확보없이기존의교육과정틀안에서 TBL 을운영하는하는방법을제안해본다. 이외에도 Brich [18] 와같이정규교육과정의보조프로그램 (supplemental program) 으로 TBL을운영하여 TBL 의교육적효과를기대해보는것도대안이될수있다. 또한효과적인 TBL 운영을위해서는 computer based test system, 원형테이블등팀학습에적합한교육환경을구축하고 [19,20], audience response system 과같이상호작용을촉진할수있는도구를활용하려는노력도필요하다 [11]. 지금까지의학교육에서 TBL의교육적효과에대한결과를제시하고있는선행연구에따르면 TBL은학생들의학업성취도를향상시키며, 교수와학생들의수업만족도를높여준다. 구체적으로 Burgess et al. [21] 은 TBL 이대규모학생을대상으로팀학습을가능하게하며지식의습득에효과적인방법이라고평가하였고, Tan et al. [22] 은 passive learning 교수법을사용한수업과 TBL로진행한수업의학생성적을비교하여, Vasan et al. [23] 은 TBL 을도입하기전과후학생들의 National Board of Medical Examiners 점수를비교하여 TBL 이다른교수법에비해학생들의학업성취도향상에도움을주고있음을증명하였다. 또한 TBL 은학생간의성적편차를줄이고, 과목낙제율을낮추며 [13] 특히성적이낮은그룹학생들의학습을돕는다 [24]. 이처럼 TBL 연구는대부분학생과교수의만족도, 시험성적을결과변수로설정하고교육적효과를측정하지만이외에도구조화된도구를사용하여학생들의정서지능 (emotional intelligence) 과임상적추론능력 (clinical reasoning ability) 을측정하여의미있는결과를보여준연구도있다. 특히 Okubo et al. [25] 은 Problem-Solving Ability Test (P-SAT) 을실시하여 TBL 을통해학생들의임상적추론능력이향상되었음을확인하였고, Borges et al. [26] 은 Workgroup Emotional Intelligence Profile-Short Version (WEIP-S) 검사결과를제시 하며 TBL 이학생들의정서지능발달에도긍정적인영향을주고있음을확인시켜준다. 또한 Bick et al. [27] 은 TBL 이기초의학과임상의학의통합을가능하게하고학생들의의사소통기술과리더십능력의향상을가져온다고보고하였으며, Parmelee & Hudes [28] 는의학전문직업성 (medical professionalism), 피드백역량을향상시키고평생학습자로성장하기위한훈련을제공해준다고하였다. 앞서논의한바와같이 TBL 은다양한교육적효과를가져오며교수와학생모두높은만족도를나타내고있는교수법이다 [18]. 하지만선행연구를통해확인된결과외에 TBL을지속적으로경험했을때기대되는다양한교육적효과에대한근거는아직제한적이다. 따라서앞으로 TBL 이국내의학교육장면에적극적으로도입되어폭넓게활성화되기위해서는국내의학교육에서의효과성을확인하고구체적인적용방안을제안하는연구들이지속적으로발표되어야할것이다. 또한 TBL에대한부정적인인식에대해서도충분한논의가이루어져야한다. 특히기본개념만확인하고지나가야할 readiness assurance 과정에불필요하게많은시간이소모되어실제적용학습에서깊이있는토론을진행할시간이부족했으며동료를평가하는것이어렵고불편했다는의견, 팀학습을중심으로진행되는수업이자신의학습스타일에맞지않아부담스러웠다는학생들의의견에주목할필요가있다 [29,30]. 따라서보다효과적으로 TBL을운영하기위해서는각단계의목적에부합되도록적절하게시간을배분해야하며, 동료평가의공정성을확보하고 [29] 학생들의학습유형 [30] 과개인적특성 [31] 을고려해팀을구성하는등의노력을기울여야할것이다. 그가운데동료평가는 TBL 의핵심이되는과정이며더나아가의사에게필수적인역량임에도불구하고이에대한저항이커교수에게는부담이되는평가방법일수밖에없으므로 [32], 객관적인평가가가능한구조화된양식을개발하고학생들을대상으로실제적인평가자훈련을제공하는등공식적인평가도구로자리매김할수있도록하기위한고민이시급하다. 결론적으로 TBL은현재의학교육이목표로하는학생중심의통합교육을실현시켜주는교수법이다. 추후보다많은국내의의과대학이 TBL 을도입하여다양한교육적효과를거두고, 그경험을바탕으로적극적인연구가진행되어 TBL 275
Yera Hur, et al : Review on the administration and effectiveness of team-based learning in medical education 이의학교육의질향상을도모할수있는경쟁력있는교수법으로자리매김할수있기를기대한다. [updated 2012 April 25; cited 2013 October 5]. Available from: http://cis.apsc.ubc.ca/services/team-based-learning. 9. The University of British Columbia. TBL students handout [Internet]. Huntington, USA: Team-Based Learning Acknowledgements: None. Funding: None. Conflicts of interest: None. REFERENCES 1. Han JJ. Global doctor s role and outcome-based medical education. Ewha Med J 2013; 36: 3-8. 2. Dent JA, Harden RM. A practical guide for medical teachers. 2nd ed. New York, USA: Elsevier Churchill Livingstone; 2006. Chapter 1, New horizons in medical education; p 2-9. 3. Parmelee DX. Team-based learning: moving forward in curriculum innovation: a commentary. Med Teach 2010; 32: 105-107. 4. MedEdPORTAL [Internet]. Washington, DC, USA: Association of American Medical Colleges; c2013 [cited 2013 October 10]. Available from: http://www.aamc.org/ mededportal. 5. Parmelee DX, Michaelsen LK, Cook S, Hudes PD. Team-based learning: a practical guide: AMEE guide no. 65. Med Teach 2012; 34: e275-e287. 6. Haidet P, Levine RE, Parmelee DX, Crow S, Kennedy F, Kelly PA, Perkowski L, Michaelsen L, Richards BF. Perspective: guidelines for reporting team-based learning activities in the medical and health sciences education literature. Acad Med 2012; 87: 292-299. 7. Parmelee DX, Michaelsen LK. Twelve tips for doing effective team-based learning (TBL). Med Teach 2010; 32: 118-122. 8. Introduction to team-based learning [Internet]. Vancouver, Canada: The University of British Columbia; c2009 Collaborative; c2010 [updated 2010 August 16; cited 2013 October 5]. Available from: http://www.teambasedlearning.org/resources/documents/tbl%20handout%20aug%2 016-print%20ready%20no%20branding.pdf. 10. Michaelsen LK, Parmelee DX, McMahon KK, Levine RE. Team-based learning for health professions education. Sterling, USA: Stylus Publishing; 2008: Chapter 2, Fundamental principles and practices of team-based learning; p 9-34. 11. Fujikura T, Takeshita T, Homma H, Adachi K, Miyake K, Kudo M, Takizawa T, Nagayama H, Hirakawa K. Team-based learning using an audience response system: a possible new strategy for interactive medical education. J Nippon Med Sch 2013; 80: 63-69. 12. Masters K. Student response to team-based learning and mixed gender teams in an undergraduate medical informatics course. Sultan Qaboos Univ Med J 2012; 12: 344-351. 13. Nieder GL, Parmelee DX, Stolfi A, Hudes PD. Teambased learning in a medical gross anatomy and embryology course. Clin Anat 2005; 18: 56-63. 14. Anwar K, Shaikh AA, Dash NR, Khurshid S. Comparing the efficacy of team based learning strategies in a problem based learning curriculum. APMIS 2012; 120: 718-723. 15. Abdelkhalek N, Hussein A, Gibbs T, Hamdy H. Using team-based learning to prepare medical students for future problem-based learning. Med Teach 2010; 32: 123-129. 16. Kim S. Student centered medical education. Korean J Med Educ 2012; 24: 279-280. 17. Hrynchak P, Batty H. The educational theory basis of team-based learning. Med Teach 2012; 34: 796-801. 276 Korean J Med Educ 2013 Dec; 25(4): 271-277.
허예라외 : 의학교육에서의팀바탕학습운영과효과성에대한고찰 18. Brich J. Feasibility, acceptance and impact of team-based learning in neurology: a pilot study. GMS Z Med Ausbild 2013; 30: Doc20. 19. Inuwa IM, Al-Rawahy M, Roychoudhry S, Taranikanti V. Implementing a modified team-based learning strategy in the first phase of an outcome-based curriculum: challenges and prospects. Med Teach 2012; 34: e492- e499. 20. Cho AR, Han SI, Yoon SH, Park JH, Yoo NJ, Kim S. Methods of effective team-based learning administration and expected effects on medical education. Korean J Med Educ 2010; 22: 47-55. 21. Burgess AW, Ramsey-Stewart G, May J, Mellis C. Team-based learning methods in teaching topographical anatomy by dissection. ANZ J Surg 2012; 82: 457-460. 22. Tan NC, Kandiah N, Chan YH, Umapathi T, Lee SH, Tan K. A controlled study of team-based learning for undergraduate clinical neurology education. BMC Med Educ 2011; 11: 91. 23. Vasan NS, DeFouw DO, Compton S. Team-based learning in anatomy: an efficient, effective, and economical strategy. Anat Sci Educ 2011; 4: 333-339. 24. Koles P, Nelson S, Stolfi A, Parmelee D, Destephen D. Active learning in a Year 2 pathology curriculum. Med Educ 2005; 39: 1045-1055. 25. Okubo Y, Ishiguro N, Suganuma T, Nishikawa T, Takubo T, Kojimahara N, Yago R, Nunoda S, Sugihara S, Yoshioka reasoning, in students with problem-based learning tutorial experiences. Tohoku J Exp Med 2012; 227: 23-29. 26. Borges NJ, Kirkham K, Deardorff AS, Moore JA. Development of emotional intelligence in a team-based learning internal medicine clerkship. Med Teach 2012; 34: 802-806. 27. Bick RJ, Oakes JL, Actor JK, Cleary LJ, Felleman DJ, Ownby AR, Weisbrodt NW, Seifert WE. Interactive teaching: problem solving and integration of basic science concepts into clinical scenarios using team-based learning. J Int Assoc Med Sci Educ 2009; 19: 26-34. 28. Parmelee DX, Hudes P. Team-based learning: a relevant strategy in health professionals' education. Med Teach 2012; 34: 411-413. 29. Thomas PA, Bowen CW. A controlled trial of team-based learning in an ambulatory medicine clerkship for medical students. Teach Learn Med 2011; 23: 31-36. 30. Wiener H, Plass H, Marz R. Team-based learning in intensive course format for first-year medical students. Croat Med J 2009; 50: 69-76. 31. Park KH, Choi CH, Jeon YB, Park KY, Park CH. Students perceptions of team-based learning by individual characteristics in a medical school. Korean J Med Educ 2013; 25: 113-122. 32. Huh S. How to administer the peer evaluation in team-based learning. Korean J Med Educ 2012; 24: 359-361. T. Team-based learning, a learning strategy for clinical 277