의과대학 신설: 새로운 지역으로의 교육 확장(AMEE Guide No. 55)

의과대학 신설: 새로운 지역으로의 교육 확장

Developing a medical school: Expansion of medical student capacity in new locations: AMEE Guide No. 55

DAVID SNADDEN1, JOANNA BATES1, PHILIP BURNS2, OSCAR CASIRO1, RICHARD HAYS3, DAN HUNT4 & ANGELA TOWLE1

1University of British Columbia, Canada, 2University of Manchester, UK, 3Bond University, Australia, 4Association of American Medical Colleges, Washington DC, USA

새로운 지역으로의 의과대학 확장

Expansion of medical student capacity in new locations

여기서 '기능적으로 분리된 캠퍼스'란 지역적으로 구분되는 장소에서 진행되는 의학교육프로그램으로서, 이러한 지리적 거리때문에 학생들을 위해서 시니어리더십, 교수, 행정, 학생지원 등을 제공해야하는 캠퍼스를 의미한다. 캠퍼스는 기존의 의과대학이나 의과대학, 의과대학을 보유하지 않은 지역 대학, 지역의 병원 또는 보건기관과 협력관계에 있을 수 있다. 이러한 캠퍼스는 전임상실습, 임상실습, 혹은 둘 다를 위한 것일 수 있으며, 모(母)의과대학과 서로 다른 설립이념을 가지고 있을 수도 있다.

By a functionally separate campus, we mean a geographically distinct medical education program where, by reason of the amount of time spent there by students or because of geographical distance, the campus must provide support services for students including its own senior leadership, faculty, administration and student services. The campus may be affiliated with an established university and medical school, with a local university that does not operate a medical school, or a local hospital or health facility. Such a campus maybe pre-clinical, clinical or both and may be philosophically distinct from its parent medical school, for example it may emphasize rural training.

Practice points

새로운 의학교육 시설을 만들고자 할 때는 그 교육기관의 '비전'이 그 지역 내에서 충분히 공유되어야 하며, 잠재적 이익이 무엇인지 이해시킬 수 있어야 한다.

. When considering the planning and development of new medical education facilities make sure ‘‘the vision’’ is shared locally and the potential benefits understood.

캠퍼스와 지역사회 간 관계가 지속적으로 강조(renew)되어야 하는데, 이는 성공의 필요조건일 뿐만 아니라, 지속가능성을 위해서도 중요하다. 

. Build and continually renew relationships across campuses and with communities. This is not only a factor for success, but important for future sustainability.

만약 가능하다면 미리 시험해보라. "점검주간"을 통해서 기존 캠퍼스의 학생과 교수가 새로운 지역에서 한 주를 보내보도록 하는 것은 새로 올 교수가 안정적으로 닥칠 일을 경험해보는 기회가 될 수 있다

. Test things out if you can. A ‘‘prototypical week’’ where students and faculty from an existing campus spend a week in a new setting is a great opportunity for new faculty to safely experience what will be expected of them and to test out potential technology.

임상교육은 실제로 진료를 하고 있는 의사들에 의해서 주로 이루어지게 된다. 따라서 이들은 그들이 교육하는 환경과 다른 환경에서, 다른 방법으로 교육받았음을 기억해야 한다. 효과적인 교수개발이 성공에 필수적이다.

. Clinical education is mostly delivered by practicing physicians; remember that they may have learned medicine in a different system, or by different methods. Effective faculty development, (teaching the teachers) is therefore critical to success.

새로운 지역에서 학생 지원의 중요성을 과소평가하지 말라. 개인적, 학업적 지원 뿐만 아니라 지낼 곳을 찾고 새로운 환경에서 새로운 문화를 만들어가기 위한 노력을 해야 한다.

. Do not underestimate the need for student support at the new site, not just in terms of personal and academic support, but also in terms of finding accommodation and developing a student culture in the new environment.

Background

21세기 초반 많은 국가에서 의사 부족을 예견하고 의과대학 확장이 빠르게 이루어졌다. 확장을 하게 된 것은 더 많은 의사가 필요했기 때문만이 아니라 의사인력의 분포가 지역적으로 불균형하다는 것에도 있었다.

In the first few years of the twenty-first century, there has been recognition that many nations will face doctor shortages. This has led to the rapid expansion of medical school enrollment in several countries. Expansion plans have been driven not only by the need for more doctors, but also by the uneven distribution of the current medical workforce both geographically and by discipline.

의과대학의 지역 캠퍼스는 새로운 현상이 아니다.

Regional campuses are not a new phenomenon.

• In the USA, the first wave of regional campuses was established in the 1970s in response to the expansion of medical school enrollment. The Association of American Medical Colleges (AAMC) reported in 2006 that 20% of the medical colleges in the USA had regional campuses (Mallon et al. 2006). These regional campuses deliver pre-clinical and clinical education or one of these elements alone. For example, the distributed education program at the University of Washington that started in 1971 (Ramsey et al. 2001) known as the WWAMI program for the five states that it serves, has seven pre-clinical campuses where students in their home states of Washington, Wyoming, Alaska, Montana, and Idaho receive the first year of pre-clinical education. Other regional campuses offer the clinical component of the education program, such as the 30 US regional campuses described by the American Colleges of Medicine (Mallon et al. 2006). 
• In Australia, regional campuses were developed in collaboration with existing medical schools to address the shortage of rural health care providers (Prideaux et al. 2001). Some of these went on to develop as independent medical schools (e.g. James Cook University). 
• In the UK, as in many countries, medical school provision is government controlled and dependent on predictions of future workforce needs. Expansions were made in medical student numbers in the late 1990s and early 2000s based on predicted UK workforce needs (Howe et al. 2004) in a time of economic growth and prosperity. Planning for workforce development and government controlled increase in student numbers has been the main driving factor for the development of several new medical schools and regional campuses (Medical Workforce Standing Advisory Committee 1997). 
• In Canada, the first fully distributed campuses – ones where the majority of the education occurs on the distributed site – were developed by the University of British Columbia (UBC) in partnership with the Universities of Victoria and Northern British Columbia in 2004 (Snadden & Bates 2005). This was paralleled by the expansion of distributed campuses in the USA (Rackleff et al. 2007) and followed by the creation of similar distributed sites elsewhere in Canada. At least, one new medical school was created as a fully distributed and community engaged school (Strasser & Strasser 2007), thus highlighting that as medical schools expand or are created there is no one model to suit all contexts, to encourage diversity or to support the varied social responsibility missions of different schools. 

왜 지방캠퍼스인가? Why regional campuses?

약간의 학생 수 증가로도 상당히 많은 복잡한 문제들이 생겨난다. 그러나 여러 문제들에도 불구하고 지방 캠퍼스의 장점들이 있다.

Expansion brings a number of challenges that can stress a medical school, though the degree of complexity is related to the number of students involved. Meticulous planning is important for any increase in student numbers, but the complexities of increasing by a small number of students rise exponentially if a school grows by 50–100 students, or doubles their class size and engages new partners at new regional sites (Bunton et al. 2008). Despite the increased complexity, there are advantages to developing a regional campus (Mallon et al. 2006).

Regional campuses

• Give medical schools access to a larger patient base and expanded numbers of clinical teachers.
• Allow a focus on disciplines such as primary care that may be more difficult to develop on the main campus.
• May attract a different cohort of applicants to the medical school.
• Can offer a different type of education such as a more clinically focused or more integrated program.
• Benefit regional hospitals by enhancing their standing as academic centers, improving recruitment and having a positive impact on quality of care (Hanlon et al. 2010).
• Benefit the local community by increasing physician recruitment, increasing civic pride and providing some economic benefits associated with an increase in social capital (Lovato et al. 2009).

단계1 : 기획 

The first steps – planning

새로운 지역 물색하기

Identification of a new campus site

새로운 캠퍼스의 기능에 달려 있다.

Identification of a new site will depend on the nature of the need for a functionally separate campus.

학생 숫자가 절대적으로 얼마나 증가하느냐와 더불의 의사의 분포에도 관심을 기울여야 한다(사회적 책무 미션)

Workforce planning considerations may not only require an absolute increase in student numbers but also attention to physician distribution. These considerations lead to more specific considerations for the location of regional campuses, as the criteria go beyond the suitability of the site to deliver education, but the appropriateness for delivery of this additional social responsibility mission. 

In Canada, the Northern Medical Program (NMP) and Island Medical Program (IMP) in British Columbia, and the Northern Ontario School of Medicine were a result of both insufficient supply of graduating physicians and an uneven distribution of practicing physicians between urban and rural regions.

작은 규모의 지역사회가 핵심 임상경험을 하기에 더 적합할 수도 있다.(평가인증 기준에도 더 잘 맞을 수 있다)

It may be a challenge in smaller communities to provide students with an appropriate set of core clinical experiences (which may be influenced by accreditation standards). Two examples from Canada illustrate creative solutions to this issue. 

파트너십 강화 Developing partnerships

Once the regional campus site has been determined, the development of a working collaboration between the parent university and partner institutions, whether they be university or health service or both, is critical. Features of partnership development include:

• 공통의 이해관계 찾기 Finding common ground
• 윈-윈 관계 형성 Creating a win–win relationship
• 공동의 비전, 미션, 목표 수립 Building common vision, mission and goals
• 주인의식 고취 Promoting ownership
• 공동의 추진원칙 수립 Acting on a set of agreed guiding principles.

Written commitment to a common mission, a set of common goals, and a clear set of operating principles at this point will prove invaluable when discussions become difficult. 

의료취약지에서는 진료의 패턴 차이가 커서 갈등의 요인이 될 수도 있다. 예컨대 취약지에서는 generalist가 해야 하는 업무의 폭이 더 넓다. 

Indeed, if the area is underserved, there may be variations of patterns of clinical practice that can create conflict. For example, the scope of practice of generalists may be much broader in an underserved regional setting that in a university-based tertiary care setting. These differences are best articulated clearly and addressed before planning gets underway.

외부적 전략도 필요하다.

External strategies to support a common purpose may include public meetings, social events, regular media contact and regular meetings with the partners, ideally with independent facilitators to get through issues where there is incomplete agreement. Internally, an intense change management strategy of engaging faculty and staff across sites becomes essential.

지원체계 구축 Building support

지역사회의 의사들과 구성원들과의 협조를 구축해나가야 한다.

As relationships are built between academic institutions, engagement with the health services sector and the community must begin. Buy-in of the local physicians is essential but may not have occurred if the partnerships have resulted from inter-institutional agreements that have not involved the physician community. The regional academic partner may be unprepared for the degree to which physicians expect to be engaged: the parameters for normal community consultation by a university may be woefully inadequate for the health care delivery community. Remuneration levels for physician executives may be shocking to the regional university and disruptive to their culture. The process of engagement is delicate: identifying and engaging the local leaders is key. Finding the supporters and early adopters will provide an initial base to build on.

취약지에서 의사들은 환자도 보고 교육도 해야 하는 것에 부담을 느낄 수 있다. 일부는 심지어 '학계'를 떠나기 위해서 왔을 수도 있다. 그러나 이들조차도 동료들이 학생들과 즐겁게 지내는 것을 본다면 무슨 일이 벌어지나 관심을 갖게 될 것이다. 

In underserved communities, physicians may feel overburdened by both looking after patients and teaching, and some may also have moved to that community specifically to escape “academia.” Most physicians, even the busy ones and those who abhor the trappings of academia, will come around when they see their colleagues’ pleasure in working with learners, so it is important to acknowledge these two statements of resistance but not be discouraged in moving forward.

어떤 사람들의 새로운 의과대학의 교육 미션과는 거의 관계도 없는 오랜 고충을 해결하기 위해서 대학, 보건당국, 병원, 정부와 협상하기 위한 수단으로 지방 캠퍼스를 생각할 수도 있다.

Furthermore, some groups may see the prospect of a regional campus as an opportunity to bargain with the university, health authority, hospital, or government to address long standing grievances that have little or nothing to do with the medical school's teaching mission. 

더 넓은 지역사회의 지원 Support in the broader community

Support in the broader community is critical to success. It is important to engage local community leaders and politicians and to find ways to ensure the local population are informed and have a chance to become engaged in the new development. A mixture of meetings with local leaders from outside of medicine, local politicians, media releases, and public events are ways of engaging.

지역사회의 비현실적인 바람을 적절히 관리하는 것이 필요하다. (경제적인 기대 등) 졸업생이 실제 진료를 하기까지는 오랜 시간이 걸릴 것이고, 오히려 실망하게 될 수도 있다.

Finally, volunteers from the community can be very helpful in terms of developing simulated and standardized patient banks and many feel they are contributing to a broader social mission. It is also important to manage unrealistic expectations from the community. There will be some economic gains with the addition of a regional campus. However, recruitment of graduates into practice will take many years, and overly enthusiastic press releases can end up with later disappointments.

초기 리더십 Early leadership

현장에서 뛰는 사람이 필요하다. 의학교육에 대해서 별로 아는 것이 없고 경험이 없을 수도 있지만, 여러 사람들을 만나고 다닐 필요가 있다.

It is likely that in the initial stages the regional campus leadership will consist of individuals who are doing this ‘off the side of their desk’. They may know little or nothing about medical education in general, have been educated in a different paradigm or country, and have little or no experience of the parent program in particular. It is important early on to identify temporary or interim leadership who can fully engage with counterparts at the main campus until a full search process can take place.

그 지역의 사람들을 참여시켜야 한다.

Involvement of local people in the selection process is key. You are looking for people who are collaborative and good communicators; credibility with the local community trumps experience in medical education.

기획 단계 Planning process

리더십이 구축되고 동의가 구해지면 구조와 절차를 기획해야 한다.

Once leadership is in place and initial agreements are set, a planning structure and process is required. This should be collaborative and formal, ensuring that progress is made toward formal recommendations and approvals of processes.

기획 단계에서 이런 것들이 고려되어야 한다. 입학에 대해서는 개교 2년 전에는 확정되어야 한다.

Planning must include necessary infrastructure including new buildings, technology requirements, and ongoing funding. Policy-intense issues such as the approval processes for budget allocations, student support and fees, allocation of bursaries across sites, and processes for faculty appointments should be sorted out at this time. Although we focus on admissions in a later section, admission processes must be finalized 2 years before the entry of the first students, and often serve as a focus for the partners in creating and agreeing on concrete processes, based on common missions and goals.

교육과정 모델이 만들어지면 기초의학자, 튜터, 임상실습강사 등을 다양한 분야에서 모집하기 위한 구체적인 내용을 결정해야 한다.

Once the curriculum model is established, a curriculum mapping exercise can provide the detailed requirements for basic scientists, tutors and clinical preceptors from different disciplines. These needs can be matched against existing resources and future hiring plans

거버넌스와 재정 Governance and finances

The more successful models have a clear, shared vision and mission, clear lines of communication and accountability, greater reliance on local decision-making to solve local implementation challenges, and clear guidance for resolving differences between partners.

인증기준에도 관심을 두어야 한다.

In designing these, it is essential to keep a close eye on accreditation requirements. 

재정 구조를 확실히 하기 위해서 어떻게 자금이 유입되고 재정적 자율권은 어느 정도 되는가를 명확히 해야 한다. 나중에 변화할 부분을 위해서 유연성이 있어야 한다. 초창기에는 명확히 기술되어 서로 동의하여 서명한 동의서가 불필요해 보일지 모르겠지만, 시간이 지나고 인력이 바뀌고 기억이 흐릿해지고 우선순위가 뒤섞이는 경우를 대비해서 반드시 필요하다.

In addition be clear about the financial structures, how money will flow and the degree of financial autonomy on the regional campuses. In the early days of building a new campus, the financial formulae used will be best guesses, so it will be important for the campus to have flexibility in how it uses its resources in order to solve unexpected problems. Clear budgeting processes, committee membership, and conflict resolution mechanisms must be agreed and written down in signed inter-institutional agreements. While these may seem unnecessary during the initial enthusiasm that goes with new developments they will prove essential in time as personnel change, memories fade and different priorities appear on the political and institutional landscapes. It is easier to write and negotiate them at the beginning than several years into operations.

평가인증 Accreditation

국가 기관에 대한 평가인증은 지방 캠퍼스가 성공하기 위해서 반드시 필요하다. 매인 캠퍼스에 집중될 것이지만, 분명 평가단은 지방 캠퍼스도 방문하고 싶어할 것이다. 

Accreditation by national agencies is essential to the success of the regional campus and requires careful thought from the initiation of the project. While the main focus of accreditation may be a variation of the program provided by the main campus, accreditation agencies will almost certainly want to visit the regional campus to ensure that there are adequate resources, a positive student experience and appropriate graduate outcomes.

기획이 종료되면 - 착수 

Once the planning is over – getting going

시설 개발 Facility development

딜레이를 대비하고, Plan B를 가지고 있어야 한다.

One of the truisms of developing new ventures is that the buildings and other infrastructure are often not completed according to the original timeframes. Developing a regional campus is a complex task, as the campus, although smaller than the main base, must have everything necessary to deliver a complex medical program. There are therefore two essential elements to the planning: allow for delays in completion; and have a ‘Plan B’.

딜레이를 인정하는 것은 일정 부분 회의적인 자세가 필요하지만, 상당히 어렵다. 

Allowing for delays in completion perhaps requires a degree of educated pessimism, but is quite difficult.

사용하지 않고 있는 지역의 시설을 이용하는 대안(plan b)를 준비해야 한다.

All of these commonly disrupt plans. Hence having a Plan B is essential – offices for faculty and other staff, teaching space, and basic IT infrastructure can be created by taking over local facilities that may be idle. 

지역 파트너들과의 관계 Relationships with local partners

Most regional campuses involve collaborative partnerships between the central university and local organizations, because that is usually the most effective and efficient way of proceeding.

시작 시점의 파트너십은 점점 지연되면서 시험대에 오를 것이다.

The initial planning (second section), outlines initial engagement of local partners to get the plan to a supported, implementable stage. However, this is really only the beginning of the partnerships, which may be tested by delays in construction, changes in policy or changes in the objectives of the partners. As at the beginning, this requires excellent communication strategies both externally and internally.

메인 캠퍼스와의 관계 Relationships with the main campus

지역 캠퍼스는 그 지역의 건강요구에 부합하는 그 자체의 미션과 에토스를 만들어야 한다.

An important variant of maintaining relationships is the relationship between the regional and main campuses. The regional campus inevitably develops an ethos and mission of its own, often based on local workforce development and meeting local health care needs.

메인 캠퍼스와 긴장이 있을 것이다. 그럴 때는 큰 그림을 봐야 한다. 

It is almost certain that there will be tensions between the main and regional campuses. At times, all partners have to look upwards toward the lofty vision and goals initially developed – the bigger picture – rather than looking too closely at the smaller steps along the way. 

교수와 직원 모집 Recruitment of faculty and other staff

특정 사람들에게는 매력적일 수 있다(self-reliant, higher risk taking tendencies). 

Recruitment of faculty to new initiatives in distant locations can be a real challenge. It may be that these positions are attractive to particular types of individuals – perhaps those with more self-reliant, higher risk taking tendencies. Traditional academic research careers are difficult to nurture in regional campuses, although there may be opportunities to build research and development around local industry strengths, local population and health care needs, and the process of developing and evaluating innovative educational approaches.

어떤 지역 리더십을 선택하느냐는 중요한 결정이다.

The choice of local leadership is a crucial decision. The leader must share the vision, be strategically flexible, be innovative, be prepared to work with all partners to push the agenda along the planned path, and be willing to adapt development in response to inevitable challenges.

교수 개발 Faculty development

Most new ventures commence with a small core ‘pioneer staff’ comprising some external people but in general a majority of local recruits. This means that faculty development is a major early priority.

가장 연구로 성공할만한 영역이 어딘가를 찾아서 집중하는 것이 좋은 초기전략일 수 있다.

An important early strategy is to determine where the best chances of research success lie. There may be local health issues (e.g. rural or indigenous population health) that will attract funding because of the location and therefore be more successful than similar research development at the main campus.

학생 선발과 모집 Student admissions and recruitment

두 가지 방법이 있다.

Because admissions processes are formalized 2 years prior to the start of classes, issues related to student admissions need to be addressed early in the relationships between partners. The easiest path for large, established medical schools is to simply select more students from their competitive pool and allocate them to the regional campus. On the other hand, local partners may prefer a local community development option that increases access for local youth to medical careers. This approach may be part of a broader local community development agenda that aims to increase participation of local people in tertiary education. 

그러나 이 둘 중 어떤 것도, 혹은 두 개의 조합도 실패할 것이다.

Neither of these paths, nor indeed a combination of them, is necessarily wrong, but it is essential to resolve any differences early. It is likely that the local community development argument will have to be acknowledged if strong local support is to be maintained – the ‘grow our own doctors’ mission is not just a powerful goodwill strategy, but it also has been shown to be effective (Hays 2001; Veitch et al. 2006). 

학생이 의과대학의 교육을 감당할 수 있어야 한다. 잠재적 학생과의 명확한 의사소통이 필요하다. 

On the other hand, sustainability of the regional campus will depend partly on the ability of the students to achieve in a demanding medical education program. In most jurisdictions, admissions are the responsibility of the faculty members, and admissions processes must be approved and defensible by the parent university senate. Development of policies and procedures that ensure potential regional campus students with high academic potential can be admitted can prove to be complex and a focus for conflict and misunderstanding. Clear communication with potential students is paramount.

교육과정 Curriculum issues

Developing regional campuses poses significant educational challenges above and beyond the challenges of establishing infrastructure and recruiting faculty. A major question to address is: to what extent is the curriculum able to be delivered at the new campus? This question has several dimensions, including 

• the mission of the new campus, 
• the content of the planned curriculum, 
• the match of clinical opportunities to the planned curriculum, and 
• the assessment of learning progress at all sites.

교육과정의 많은 부분은 면허시험기관(의 학습목표)에 의해서 결정된다.

In most jurisdictions the curriculum is largely determined by national licensing organizations, following a set of learning outcomes that define the capability of graduates from the relevant curriculum. Depending on the level of the program being delivered at the satellite campus, the challenges are different. 

실험 기자재 필요

For example, in early years the requirements are for the delivery of similar basic, behavioral and social science. This may include anatomy and physiology laboratory facilities. Lectures can be delivered across several sites by video or web-conferencing. 

균등한 수준의 임상경험을 쌓을 수 있어야 한다.

For more senior years, the challenge is to provide the appropriate clinical learning opportunities, which requires an appropriate range of patients, clinical problems and clinical investigation technology. While opportunities for clinical learning always vary, even within a single site, there needs to be equivalence of opportunities at all sites in order to prevent the perception that satellite campuses are less effective as learning environments. 

모든 캠퍼스의 학생들은 같은 기준과 방법에 의해서 평가받아야 한다.

Similarly, it is essential that students at all campuses be assessed in the same ways to the same standards.

두 캠퍼스에 대해 같은 평가를 하는 것이 손쉬운 방법이다.

In the US and Canada, assessment of students must be equivalent across the sites in order to meet accreditation requirements. The simplest way to start is to employ the same assessment methods and materials at the main and regional campuses. When all students take the same sets of exams, the results provide a rapid measure of comparability of academic performance across sites. Talent at the distributed site can be channeled toward contributions to the overall assessment pool (e.g. multiple choice questions) rather than to the development of a parallel assessment system. Effective, valid, and reliable assessment of student performance in small group activities (clinical skills, problem-based learning) by new tutors at the distributed site requires faculty development, peer support and mentorship. 

새로운 캠퍼스에서 활용하기 위한 교육, 평가 기술을 개발해야 함.

There are several approaches to developing the teaching and assessment skills of faculty at the new site. These can be used in combination, for example:

• send a small number of faculty to the main campus for short periods of training;
• send faculty from the main campus to the site for faculty development workshops, peer observation, support and mentorship;
• create opportunities for tutor development meetings and workshops by videoconference. 

한 번에 끝나는 과정이 아니다.

It is important to see this as a “train the trainer” ongoing process, not a one-time only endeavor. In a supportive, mutually respectful environment, experienced faculty at either site can observe and provide feedback to less-experienced tutors, enhancing the ability of new faculty to teach and assess students until a satisfactory level of proficiency has been reached. The initial learning curve is steep; lasting at least 2 years, fortunately this is when the body of new faculty is commonly enthusiastic, stable, and turnover is low.

지역 캠퍼스가 메인 캠퍼스보다 덜 만족스럽다는 인식은 대체로 틀린 것으로 드러났다.

In practice, the perception that regional campuses are less satisfactory than the main campuses is generally almost always proven to be incorrect. Curriculum relevance of clinical experience has been shown in the UK to be equivalent in distant community general hospitals to that in larger academic hospitals (Colquhoun et al. 2009). Student performance in centrally managed assessment has also been shown not to disadvantage learners at distant campuses (Worley et al. 2004; Bianchi et al. 2008). Indeed, many students and faculty believe that regional campuses often provide richer learning opportunities, with more general clinical case mix, lower student:patient ratios, and better opportunities for students to participate in patient care. There are a few students who may do better with the anonymity of the larger campus, but many of these students end up singing the praise of the regional sites. 

그럼에도 불구하고, 일부 메인 캠퍼스의 교수들은 지방 캠퍼스의 학생들이 뒤떨어질 것을 우려하고 있다. 공식적, 비공식적 의사소통 과정을 통해서 잘 설득해야 한다.

However, in spite of the evidence and the student acceptance, the faculty at the parent site may be anxious that the student outcomes at the regional campus will lower the outcomes overall of the medical school: it is important to articulate and address this issue through both formal and informal communications processes and local evidence.

인증기준에 어긋난 것이 아니라면 그 지역사회에 가장 잘 맞는 교육과정을 만드는 것이 좋다.

If the intention is to set up a campus that will in time be independent, thought needs given as to whether to import a curriculum from elsewhere or develop one locally. If accreditation processes allow, there is merit in developing a curriculum that truly matches the needs and challenges of the local community, rather than to use one that was developed in a separate context that may have less relevance. A modern curriculum that employs strategies to reduce the burden of factual information would include a combination of didactic, small group and clinical experiences. This will determine the types of faculty required to teach and opportunities to choose from a variety of modes of delivery.

기술의 활용 Use of technology

임상실습이 아닌 거의 모든 교육과정이 온라인으로 제공될 수 있다.

Communications technology has developed rapidly to the point where virtually all of the non-practical curriculum could be delivered from the main base. 

그러나 모든 사람이 이러한 방식을 즐기는 것이 아니므로, 혼합할 필요가 있다.

However, in reality not everybody enjoys participation purely through communications technology. Hence there will almost certainly have to be a combination of distant and local delivery. This raises an important philosophical issue: the aim in using communications technology must be to facilitate or enable optimal curriculum delivery. This is a more learner-focused than technology-focused approach, but there are several challenges. 

• One is how to closely align the curriculum with the technology, as there are no clear guidelines and perhaps as many variations as there are curricula. 
• Another is the issue of compatibility of the technology backbones of the partners, as this is unlikely to be complete. 
• Finally, the continuing rapid development of communications technology may mean that regular improvement may be constrained by funding availability.

파일럿 프로그램 Local piloting of the program

As with any new initiative, it is unwise to commence full operation without some piloting and probably a staged introduction. Technology should be trialed well before it can be relied upon. Local curriculum implementation should be piloted, perhaps with a small group of volunteer students in the previous academic year.

프로그램 평가 Program evaluation

시기별 목표가 다를 수 있음

Program evaluation is essential to the success of the program and requires a solid funding envelope. Although the 

• early focus is on evaluation to improve quality, to document student achievement and satisfaction, comparability, and matching rates into postgraduate training, a 
• longer term focus is on measurement of the degree to which the program is meeting its stated mission and goals, as well as identification of unintended outcomes. 

관계자들에게 보고서 제출해야 함

It is imperative to provide regular reports to stakeholders, including future students, on program indicators. 

메인캠퍼스와 지역캠퍼스는 관점이 다를 수 있다.

Main and regional campuses have different points of view about program evaluation. 

• Central university may be focused on their usual parameters of success such as academic achievement of entering students. 
• However, the regional campus may be more interested in the impact on workforce recruitment, and on the community overall.

Planning program evaluation during the hectic start-up days can be challenging. The recruitment of an individual whose position has this as a priority has led to success at many regional sites. Impact on recruitment and workforce appears to take place well before graduation of a cohort – the regional campus itself can act as a magnet for clinicians. Capturing these changes in the first years of the program is important, as the baseline precedes any announcement of the regional campus.

장기적 ROI측정을 위한 전략

Strategies should be developed early to measure the long-term return on investment with respect to the entry of graduates into primary care and generalist specialties, the recruitment of clinicians to the region, who were students educated at the regional campus, and changes in research funding. At the same time, attention must be paid to managing expectations, especially those of community and government. 

장기적 DB구축과 이를 위한 관련 결정사항들

A longitudinal database affords the opportunity to set up a linked data collection system. However, policies to gather data in one place, decisions about what data to collect, and codebooks defining the data must all be developed requiring institutional commitment, discussion, and significant funding to implement and maintain. Establishing the need for this at the central university may be difficult when there are other funding priorities.

브랜드를 구축하고 명성을 쌓는데 필수적인 요소이다.

Program evaluation is an essential component to branding and developing a reputation. Program leaders can learn from the students and collect supporting data on what is seen as positive in the regional campus, and can communicate these to potential applicants. Other key messages will come through in terms of national exam performance and matching of graduates to competitive specialties, strengthening the appeal of the regional campus. A communication strategy, formal or informal will coordinate communication across key stakeholders, the medical education community, and the central university. Being praised by others can help the process of acceptance and cultural change at the central university.

학생 지원 Student support

From the student perspective, easy access to local support is critical. This may include the provision of advice on accommodation and finances, academic support for students in difficulty, career guidance and services for students with health and personal issues.

Pitfalls to avoid in the early years

의사와 지역사회의 참여 Physician and community engagement

변화에 대한 저항은 피할 수 없으므로, 미리 예상하고 해결해야 한다.

Resistance to change is unavoidable and should be anticipated and addressed by the program leaders through a change facilitation process that involves the education team, the health care team and the community at large.

지속적인 참여를 놓치지 않는 것이 중요하다.

Once the campus is established, it is critical not to lose sight of the importance of maintaining engagement.

변화관리 프로세스의 중요성을 언급하고자 한다.

We mentioned the importance of change management processes in the previous stages, they become even more important at this stage to ensure the overall mission stays on track.

의사소통 Communication

Institutions, organizations, and groups with different “cultures” may have a history of poor communication and mutual mistrust.

면대면 vs 원거리 Face to face versus distance issues

These pertain to faculty, administrators, and students alike. Use of technology for faculty and administrative meetings facilitates curriculum planning and faculty development. Effective use of face-to-face meetings can facilitate team building across the sites. For example, it is important to ensure that people who do not know each other meet in person at an early stage and at appropriate intervals thereafter. Developing the inter-site team and nurturing positive inter-site relationships are essential to build a team of faculty and staff who can work together to sustain the new site. A shared sense of purpose and commitment should be accompanied by efforts to ensure open, timely communication in an atmosphere of mutual respect. Avoidance of “finger-pointing” and a focus on systems issues rather than blaming individuals when mistakes occur are helpful strategies. Further suggestions to nurture the team include:

• 정기적으로 자주 의사소통 Establish regular and frequent communication with course directors and staff at other sites
• 교원모집, 교수개발, 신기술 도입에 관심가지기 Pay careful attention to faculty recruitment, faculty development and introduction to new technologies
• 확장성, 유연성을 가진 팀빌딩 촉진 Promote team building with a focus on flexibility and adaptability at all levels
• 면대면 미팅의 활용 Use face-to-face meeting time to develop rapport with colleagues at other sites
• 지역별 팀간 긍정적 관계 Expect and encourage positive local and inter site team relationships
• 팀 사기를 증진시키기 위한 이벤트 Hold events that promote a team spirit
• Recognize contributions through formal and informal means such as letters of thanks, certificates of attendance at events and workshops, awards of promoted status

역량강화와 핵심 인력 모집 Capacity building and recruitment of core faculty

Regional campuses tend to get going on a wave of enthusiasm and the energy of “early adopters”(Rogers 1983). There remains a need continue to build educational capacity in the early years and one can anticipate the need to appoint some new course leadership and expand teaching faculty within the first 5 years.

핵심 인력 모집 Recruitment of core faculty

장기간에 걸쳐서 모집하는 것이 합리적이다.

There may be some sense in staging the recruitment of full time academic faculty over a period of time. They may come from the local environment or be recruited from elsewhere.

서로 다른 경력수준에 있는 팀을 만드는 것이 합맂거이다.

There is sense in developing a team that is composed of individuals at different stages of their academic career particularly if recruitment is difficult and the team will primarily be junior in experience, consider gradually phasing them in over a period of years. 

팀빌딩 Team building

The site leader must build a core team of faculty and administrative support staff to sustain implementation and coordination efforts.

Maturing and sustaining beyond the first years of program delivery

초반이 지나면 long-term sustainability에 관심을 가지게 된다.

For the first years of development for a regional campus, the focus is on developing and implementing an undergraduate medical education program. Once the first cohort has graduated successfully, some of the pressure is lifted, and attention must turn to the implementation of a plan for long-term sustainability. 

새로운 프로그램/교과목 담당자들은 지역 캠퍼스를 자원을 잡아먹는 곳으로 보며, 스스로 문제를 해결하도록 놔둘 것이다.

New course directors or program staff at the regional campus may be seen as a drain on resources and left to work out things for themselves.

이러한 이슈를 바라보는 한 관점은 사회적 자본의 측면에서 보는 것이다.

One broad way to consider this issue is in terms of social capital (Lovato et al. 2009; Hanlon et al. 2010). As the program is built, new partnerships and collaborations are formed, increasing the social capital in the medical program faculty and staff. Over time, delivery of the program draws on this social capital, and depletes the store. The strategies identified earlier for managing change and engaging the community remain just as important once the campus is established. It is also helpful to find new opportunities to engage faculty and staff such as program innovation, continuing professional development and research. Formal recognition such as teaching awards acknowledges the hard work done. In medically underserved settings, specific clinician recruitment will be required to sustain a program over time, allowing for illness, withdrawal after an intense period of start-up and other sudden changes. Without built-in redundancy in teaching faculty developed over time, the program will become increasingly tenuous.

새 캠퍼스가 열리면 5년 내에 리더십 전략을 검토해야 한다.

As well as developing capacity in teaching faculty, the regional campus will need to examine its leadership strategies within 5 years of start-up. The academic leader will be increasingly pulled into development of research and postgraduate training, but the undergraduate program will still require a steady hand. One strategy is to recruit associate academic leads.

교육과정 변화 Curricular change

Most schools that are building regional campuses do not make major changes to the curriculum at the same time. New regional faculty may be getting used to new ways of teaching medical students that they themselves have never experienced, such as PBL and simulation.

메인 캠퍼스의 압력이 있을 수 있음.

There may be pressures on the main campus to prove that the program can be delivered at the regional campus without change to either the underlying pedagogies or the curriculum itself. The departmental structure, the power structures, and the underlying history at the main campus may make some innovations and change especially difficult.

몇 해 교육을 진행한 이후에는 그 지역 캠퍼스에도 교육 전문가가 등장할 것이다.

After several cohorts of students, however, the expertise in medical education at the regional campus will evolve. Faculty members may have deliberately increased their expertise in medical education through higher degrees, conference attendance, and professional development

이 지점에서 지방 캠퍼스와 메인 캠퍼스 사이의 혁신과 변화에 대한 긴장이 나타난다.

Tensions for innovation and change may emerge between the regional campus and the main campus at this point. Processes of curricular change, including university senate review and approvals may be completely incomprehensible to regional faculty, and may be interpreted as “stalling” on the part of the main campus. 

변화 관리 Managing change and transitions

In the early years of the regional campus implementation, university, community, health services, physician, government, and faculty of medicine leadership are all aligned to the successful implementation of the regional campus.

리더십이 바뀌는 시기는 지방 캠퍼스에게는 위기가 될 수 있지만, 이 때야말로 기초 문건을 다시 볼 때다.

Leadership transitions are times of risk for regional campuses. This is a time to revisit the foundational documents of the program.

정부가 바뀌는 것에 대해서도 잘 대처해야 한다.

Government transitions in particular need to be carefully handled. “Stories” that resonate with the new government's agenda may allow the government to accept and personalize the regional campus as contributing to “our” mission.

파이프라인 구축 Developing a pipeline: postgraduate training programs

Some undergraduate regional campuses are built on the existing success of postgraduate programs in the region.

Accreditation processes for postgraduate training, particularly in the specialties, may pose a significant barrier to development of a full training program. 

연구 문화 만들기 Developing a culture of scholarly enquiry

In the early years of a regional campus, the focus is on developing and delivering the program. Over time, there is a need to shift both the physician culture and the early program culture to developing a culture of scholarship, including research (Kaufman et al. 1996).

교육에 대한 투자를 감안했을 때, 연구 아젠다로 삼아야 할 첫 번째 분야는 의학교육이다.

Given the investment in education, one of the first areas for the development of a research agenda may be medical education.

일부 지방 캠퍼스는 기초의학과 임상연구도 할 것이다.

As well as the potential for reporting of innovations and educational research, some regional campuses will be building basic science and clinical research. This development is delicate with multiple tensions

메인 캠퍼스에서는 지방 캠퍼스에서 어떻게 연구를 할 것인가에 대한 이해가 부족할 수 있다.

In general, because the main campus is usually a much larger faculty with research centers and large multidisciplinary research teams, there is little understanding of how to facilitate research at a regional campus.

If the development of the research programs is so difficult, what are the rewards? First, it is a general expectation (and sometimes an accreditation requirement) that medical students will have opportunities to engage in research. 

Successful scholarly programs for students attract a different applicant pool, and alter the perception of a rural regional campus as a “training site for barefoot doctors.”

인력 모집과 유지 Recruitment and retention

For most regional campuses, recruitment of their graduates in the region is an important outcome and recruitment of future colleagues is an important reason for engagement of clinicians. As many graduates move for postgraduate training, staying in touch and connected is an important strategy for future recruitment. Engaging the health authority in recruitment strategies and ensuring that the health care system is supportive and ready for their integration as clinicians will ensure that at least some graduates return after postgraduate training.

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Med Teach. 2011;33(7):518-29. doi: 10.3109/0142159X.2011.564681.

Developing a medical school: expansion of medical student capacity in new locations: AMEE Guide No. 55.

Snadden D1, Bates J, Burns P, Casiro O, Hays R, Hunt D, Towle A; Association for Medical Education in Europe.

Author information

• 1University of British Columbia, Canada. snadden@unbc.ca

Abstract

BACKGROUND:

A concern about an impending shortage of physicians and a worry about the continued maldistribution of physicians to medically underserved areas have encouraged the expansion of medical school training places in many countries, either by the creation of new medical schools or by the creation of regional campuses.

AIMS:

In this Guide, the authors, who have helped create new regional campuses and medical schools in Australia, Canada, UK, USA, and Thailand share their experiences, triumphs, and tribulations, both from the views of the regional campus and from the views of the main Medical School campus. While this Guide is written from the perspective of building new regional campuses of existing medical schools, many of the lessons are applicable to new medical schools in any country of the world. Many countries in all regions of the world are facing rapid expansion of medical training facilities and we hope this Guide provides ideas to all who are contemplating or engaged in expanding medical school training places, no matter where they are.

DESCRIPTION:

This Guide comprises four sections: planning; getting going; pitfalls to avoid; and maturing and sustaining beyond the first years. While the context of expanding medical schools may vary in terms of infrastructure, resources, and access to technology, many themes, such as developing local support, recruiting local and academic faculty, building relationships, and managing change and conflict in rapidly changing environments are universal themes facing every medical academic development no matter where it is geographically situated.

FURTHER INFORMATION:

The full AMEE Guide, printed separately, in addition contains case examples from the authors' experiences of successes and challenges they have faced.

PMID:

 

21696277

 

[PubMed - indexed for MEDLINE]