세계화, 경제, 그리고 전문직업성 (Med Teach, 2015)

세계화, 경제, 그리고 전문직업성 (Med Teach, 2015)

Globalisation, economics and professionalism

CHAY-HOON TAN1 & PAUL MACNEILL2

1National University of Singapore, Singapore, 2University of Sydney, Australia

세계화는 상호작용과 통합의 과정이다. 세계화라는 단어는 Friedman을 비롯한 여러 작가들이 산업과 경영에서와 같은 시장영역에서 세계화라는 단어를 사용하면서 유명해졌다. 세계화는 그러나 그 범위가 더 넓어져서 경제 영역을 국내는 물론 해외에까지 개방한 정책 등까지 넓어졌다. 이러한 과정을 의사소통의 속도와 단순성을 향상시킨 기술 혁신의 도움을 받아 극적으로 지식과 자원의 전 세계적 교류를 향상시켰다. 국가간 상품과 서비스의 이동성을 가로막는 장애물을 점차 더 적어졌다. 세계화라는 단어는 인간의 노력이 들어가는 여러 분야에 넓게 확장되었다. 세계화라는 단어가 '글로벌 헬스케어'라는 용어에서도 볼수 있듯 의료에까지 영향을 주었음은 물론이고, 의료 관련 행위들에 대하여 국경도 쉽게 넘나들고 있다. 이러한 것은 의료진의 이동이나, 약품의 이동, 그리고 의료 관광객(수술, 이식, 심지어 안락사까지)들에 의해서 일어난다. 세계화는 의학교육에도 영향을 주었고, 의료윤리, 의료전문직업성에도 영향을 준다.

Globalisation is a process of interaction and integration. The term‘globalisation’ was popularised by many writers includingFriedman (2005) who used the term globalisation to refer tothe market place associated with business and industry.Globalisation has been however extended much further, bypolicies that have opened economies domestically and inter-nationally. This has been aided by technological innovationsthat have enhanced the speed and simplicity of communica-tion and dramatically increased exchanges of knowledge andresources across the globe (Sciarra et al. 2014). There are nowfewer obstacles to the mobility of products and services acrossnational borders (Dalmolin et al. 2013). The word ‘globalisa-tion’ has spread extensively into many fields of humanendeavour (Balasubramanian et al. 2015). Inevitably, global-isation has affected medical practices as is evident fromnotions of ‘global healthcare’, and from the relative ease ofcrossing of national borders – for medically related activities –by the movement of medical staff, by pharmaceutical products(and the ‘off-shoring’ of clinical trials) and by ‘medical tourists’– seeking surgery, organ transplants and even medical euthanasia. Globalisation has also influenced medical educa-tion, medical ethics and medical professionalism (Frenk et al.2010; Crone & Samaan 2013). 

의학과 의료에 관한 우려는 이제 전 세계적인 문제가 되었다.

Concerns about medicine and medical practice now needto be addressed globally

보험 

Insurance 

카네기재단이 1900년대 초반에 지원하여 이뤄진 플렉스너의 연구는 의료 전문직업성의 토대를 지식을 이타적으로 사용하고, 환자와 의사의 신뢰를 기반하는 것이라 묘사했다. 플렉스너의 이타적인 비전은 사회 변화에 따라서 엄청난 저항을 받게 된다. 1920년대의 대공황은 미국에 고용주가 지원하는 건강보험 형태를 가져왔고, 이는 '회사들이 비용으로 처리하여 세금을 감면받을 수 있는 능력'으로 더 촉진되었다. 이러한 경향은 공격적인 의료 마케팅에 지원을 받는 행위별 수가제에 의해서 또 한번 촉진되었으며, 이는 '최고와 최신의 기술의 사용이 권장'되었기 때문이다. 모든 비용이 보험에 의해서 커버되면서 많은 환자들은 최고의 그리고 최신의 비싼 치료를 받기를 원하게 되었다. 또한 회사가 이렇게 나오자 병원들도 서로서로 최고의 최신의 치료를 위해 경쟁했으며, '절차주의자(proceduralist)가 내과 외과를 모두 장악하기 시작했다. 이러한 미국의 보건의료정책과 의료행위는 국제적으로 퍼져나갔다. 미국의 의료사업은 국제적 현상이 되었다.

In the landmark study funded by the Carnegie Foundation inthe early 1900s, Abraham Flexner described the underpinningof medical professionalism as knowledge used in an altruisticfashion and based on a trust between the patient and thetreating doctor. Flexner’s altruistic vision, however, met con-fronting challenges brought about by societal change. The greatdepression in the 1920s led to a rise in employer-sponsoredhealth insurance in the USA – a trend that was further fuelled bythe ‘‘ability of companies to take a full tax deduction for their costs’’. This trend was added to by a ‘‘fee-for-service system, aided by aggressive new medical marketing’’ which ‘‘encour- aged use of the latest and the best’’ (Wenger 2007). With costs covered almost totally by insurance, many patients demanded only the best and most expensive treatment. Furthermore, with ‘‘corporate encouragement, hospitals began to compete with each other to deliver the latest and best, with proceduralists beginning to dominate both medicine and surgery’’ (Wenger 2007). This trend of US healthcare and practice spread globally (Reif & Whittle 1997; Neill 2015). US business expansion in healthcare services has become a global phenomenon (Health and Medical 1997) and predominates over health concerns.

임상 진료

Clinical practice 

의학이 가장 헌신해야 할 것은 환자의 최선의 이익이다. 그러나 이는 헬스케어가 기업의 영역이나 개인의 이익의 영역에 들어갈 때 더 이상 유지하기 어려워진다. 이에 더하여 보건의료제도의 접근성의 변화는 부유한 사람은 그게 세계 어디에 있든 바로 접근 가능하게 되었다. 이는 가난한 사람들의 희생으로 부유한 사람들에 대한 의료를 향상시키는 결과를 가져왔다. "경제성 평가에 대한 유혹은 의사들로 하여금 그 전문직의 핵심 가치를 훼손시키는 결과를 가져왔다" 의료 전문직은 이제 금전적 이익을 가장 최우선으로 두는 것처럼 보여지게 되었고, 적절한 임상 행위의 조절, 진료의 진실성 등이 부족한 것으로 인식되게 되었다. 

The primary commitment of medicine is to serve patients’ bestinterests. But this is difficult to maintain in the face of globalshifts in the control of healthcare delivery either towards thestate or towards the corporate sector and individual interest(Casalina 2013). In addition, changes in the availability ofhealth care services, both nationally and internationally, allowthe rich to seek medical care wherever it can be found. This inturn leads to increased pressures to care for the rich at theexpense of the poor. The lure of ‘‘economic advantage hastested, and often undermined, practitioners’ commitments tocore values of their professional’’ (Faulconbridge & Muzio2009). The medical profession is increasingly seen as con-cerned primarily about financial gain, lacking in adequateregulation of clinical behaviour and skills, and lacking honestyin practice (Cruess & Cruess 2004; Bernat 2014). 

시나리오: 과도하게 비용을 청구당하는 해외 환자

Scenario (Over-charging an International patient)

글로벌 헬스케어는 의료를 산업화 하였다. 자유시장을 가능하게 하여서 가장 비싼 최신의 치료의 활용을 촉진시켰다. 비약리적으로 사용되는 항생제의 pandemic한 사용은 문화와 경제적 요인에 의해 영향을 받는다.

Global health care, however, tends to advance medical practice as an economic enterprise. It enables free trade and promotes the use of the latest most expensive medical treatment. The pandemic use of antibiotics used non-pharmacologically is shaped by culture and economic factors (Avorn & Solomon 2000).

시나리오: 말기암환자 치료에 관한 프로페셔널리즘

Scenario (professionalismof treating patients with end stage cancer)

개인병원 암 전문의가 환자와 치료의 위해(의료적, 경제적)에 대해 이야기를 꺼리는 것, 그리고 치료에서 얻을 수 있는 이익이 거의 없는 것은 암 전문의의 전문가적 역량에 의문을 제기한다.

The private oncologist’s reluctance to discuss the risks (both medical and financial), and the slim likelihood of any benefits from the treatment, raises serious questions about the oncologist’s professional competence (Mohanti 2009).

헬스케어의 세계화 : 의료 관광

Globalisation of healthcare: medical tourism

시나리오 (의료 관광) 

Scenario (medical tourism)

외국 환자에게 의료를 제공하는 것은 빠르게 확장되어가는 의료 관광산업으로, 600억달러에 달한다. Snyder 등은 의료전문직의 의료관광에 대한 역할에 대해서 서술한 바 있다. 이것이 자국과 자국 의사, 의료기관에는 경제적으로 도움이 될지 몰라도 자국민의 의료서비스에 관해서 심각한 갈등을 초래할 수도 있다.

The delivery of global healthcare to international patients has spawned a growing and lucrative medical tourism indus- try, said to be worth US$60 billion (Jones & Keith 2006; Gwee et al. 2013). Snyder et al. (2011) described the roles for medical professions in the tourism industry. While this is economically beneficial to the host country, the treating doctors and to health care institutions, it can also pose a potential source of conflict with the delivery of healthcare to the citizens of the host nation.

세계화와 의학교육 

Globalisation and medical education

많은 국가들이 교육과 평가에 대한 공통의 기준을 도입하고 있다.

The adoption across many countries of common standards for teaching and assessment 

더 중요한 것은 공통의 기준으로 인해 의과대학과 전공의 교육에 대해서 국가간 이동이 허용되었다는 것이며, 교사들도 다른 국가로 이동이 가능해졌다는 것이다.

More importantly, common standards have allowed for transnational training of both undergraduate and postgraduate medical professionals as well as for the movement of medical teachers across the globe.

의학교육에서 세계화의 영향은 그 이득과 피해에 대한 평가가 필요하다. 의학교육도 사업이 되었다. 일부 미국, 영국, 호주의 대학은 다른 국가의 병원, 기관, 의과대학과 파트너십을 맺었다. 이러한 파트너십은 다양한 형태를 띈다. 일부는 구매자의 명성을 올리기 위하ㅏ여 '브랜드'를 '구입'하기도 한다. 어떤 경우에서는 교육과정과 평가도구를 패키지로 판매하기도 한다. 인적자원도 이러한 협약의 대상이 된다. 또 다른 모델은 '공동 브랜드' 혹은 '의과대학 전체의 업무 위탁'으로서, 카타르의 Weill Cornell Medical College가 그 예이다.

The impact of globalisation on medical education needs to be evaluated in terms of its benefits and potential harms. Medical education has become a business enterprise. Several medical schools in the USA, the UK and Australia have entered into partnerships with hospitals, institutions and medical schools outside of their own country (Tsai 2012). These partnerships take different forms. In some cases, a ‘brand’ is ‘purchased’ to enhance the prestige of the purchaser. Other situations involve the sale and purchase of curriculum pack- ages and assessment tools. Human resources such as teaching faculty may also be included in the agreement. Another model 852 is the ‘‘co-branding’’ and ‘‘‘off-shoring’ of a whole medical school’’ as epitomised by the new Weill Cornell Medical College in Qatar at a contractual cost of USD750 million for 11 years. (Hodges et al. 2009). Green (2007) commented that the Cornell-Qatar partnership ‘‘is a revenue stream’’. In another example, the Medical Education Partnership Initiative provided $130-million over 5 years to 13 African medical schools from the U.S. government (Omaswa 2014). 

세계화 뒤에는 엄청난 돈의 흐름이 있다. 그러나 이러한 협약이 치뤄야 할 숨겨진 비용이 있다. 파트너 의과대학에서의 의학교육자들은 그것을 구매한 국가에 적절하지 않은 교육방법을 수입해올 수 있다. Lim의 관점에 따르면 의료기관의 질이 크게 손상되게 된다. 또한 "세계화의 경제적 측면을 지나치게 강조하는" 환경에서는 의과대학생의 프로페셔널리즘과 태도에 큰 영향을 줄 수 있다.

These are considerable sums of money and draw attention to the business motivation behind globalisation. The arrangements, however, may come at some hidden cost to the host countries. Medical educators from ‘partner’ medical institutions are more likely to conform to imported educational approaches and standards of practice which may not be appropriate in the host country (Ho et al. 2011). The quality of the medical institutions can be heavily compromised in Lim’s view (Lim 2008; Lum 2011). There are also serious concerns about the effect on the professionalism and attitudes of medical students in an environment of on ‘‘overemphasis the economic aspects of globalisation’’ (Hodges et al. 2009).

제약산업과 세계화

Globalisation and the pharmaceutical industry

약의 접근성이나 신약 개발의 우선권은 주로 제약산업의 손에 달려 있다.

The availability of drugs and priorities in developing new drug treatment is largely in the hands of the pharmaceutical industry. 

문제는 그 산업계가 이익을 중시하는 회사의 손 안에 있다는 것이다.

The problem, however, is that industry is largely dominated by for-profit companies. Marcia Angell (former Editor of the New England Journal of Medicine), in her book The Truth About the Drug Companies (and a previous article with the same title) makes a strong case for claiming that the industry is dominated by the profit motive (Angell 2004a,b; Hoey 2004). 

대형 제약회사 (약 10개 정도의 다국적 기업)는 어마어마한 부와 정치력을 가지고 있다.

Big Pharma – the collective name for 10 or more very large multinational companies – have enormous wealth and political power. The global pharmaceutical market was estimated 10 years ago at about US$20 billion per annum although, when all drug expenditure is taken into account, it can be as much as $400 billion (Angell 2004a,b). 

이러한 힘과 영향력의 영향은 세계화에 의해서 더 악회된다. 예컨대 호주에서는 제약회사들이 국가 기관의 결정에 항의하는 일이 있었다.

The concerns about the power and influence of drug companies are exacerbated by globalisation and the influence of companies across national borders. In Australia, for example, which has a well-established drug evaluation programme that limits the extent to which drugs can be subsidised by the national health system, drug companies have challenged decisions of the Pharmaceutical Benefits Advisory 

자유 무역 아래에서는 의원회의 결정의 제약된다. TPP는 이를 더 악화시킬 것이다.

Committee (e.g. in not admitting new drugs when an equivalent drug arguing that the generic was available) decisions are constraints on free trade (Quiggin 2010). There is further concern that a new Trans-Pacific Partnership will add to the pressure (Sheftalovich 2015).

John Le Carre의 소설에서 제약회사의 타락을 극적으로 그린 바 있다. 이는 많은 경우 실제와 다르지 않다.

Whilst John Le Carre´’s novel The Constant Gardener presented an extreme (fictional) account of corrupt behaviour by pharmaceutical companies, it is apparent that there have been many instances of corruption in reality (Groeger 2014).

또한 다국적 임상시험도 우려스러운 것 중 하나다. 다음의 이유로 인도는 국제적 임상시험의 매력적인 장소가 되었다.

There are also concerns about trans-national clinical trials of drugs (Lang & Siribaddana 2012). The availability of a large drug-naı¨ve patient population and well-trained medical professionals, coupled with sophisticated technological infrastructure, has made developing countries like India attractive destinations for conducting global clinical trials. Jayaraman (2004) reported that many clinical trials are conducted in a ‘‘rash and risky’’ manner, which raises questions about the professionalism of the investigators and their regulatory bodies.

제약산업의 힘 

The power of the pharmaceutical industry 

탐욕스러운 가격책정과 의심스러운 의료행위. 약값은 그 약을 만드는데 들어간 비용과 거의 관계가 없다.

The consequences of the global influence of drug companies are enormous. These include the growing cost of medical treatment, to which pharmaceutical products contribute the greatest proportion. Yet ‘‘prices are much higher for precisely the people who most need the drugs and can least afford them’’. Angell accuses the pharmaceutical industry of ‘‘rapacious pricing and other dubious practices’’ and claims that the ‘‘prices drug companies charge have little relationship to the costs of making the drugs and could be cut dramatically without coming anywhere close to threatening R&D’’ (Angell 2004a).

의과대학의 독립성

Independence of medical schools 

가장 우려되는 것은 의료전문직과 의과대학의 독립성이 훼손될 수 있다는 우려이다. 의과대학과 교육병원의 기풍(ethos)이 변화하고 있다. 의과대학은 제약산업에 연구와 많은 경우 자본 개발에 의존적이 되어가고 있다. 점차 독립성을 유지하기가 어렵다 

A principal concern is that the independence of the medical profession, and medical schools, have been compromised through their relationships with Big Pharma – a relationship which has ‘‘transformed the ethos of medical schools and teaching hospitals’’ (Angell 2004a). Medical schools have become dependent on the pharmaceutical industry to support research and, in many cases, for direct support in capital development. It becomes increasingly difficult to maintain independence, let alone a critical stance, at the risk of losing significant funding. And for many reasons, as Angell points out, there ‘‘has been a growing pro-industry bias in medical research – exactly where such bias doesn’t belong’’.

Conclusion

Globalisation has its benefits in creating a more cohesive world with more porous borders, but it has blurred the definition and practice of medical professionalism. Proponents of globalisa- tion argue that it allows poor countries and their citizens to develop economically and raise their standards of living. Harden (2006) suggests globalisation is the way to achieve the goals for higher education. Opponents of globalisation claim that the creation of an unfettered international free market has benefited multinational corporations in the Western world at the expense of local enterprises, local cultures and common people. Economic factors including payment models affect professionalism (Moser 2009; Collier 2012). In assessing globalisation’s effect on professionalism, there is a need for appraisal at the intrapersonal, interpersonal and institutional levels and for evaluation of its effect on society at large (Hodges et al. 2011). The medical profession must recapture for itself the critical function of what constitutes excellence (Heller 2012) and align the goals of the organisation, accountability and professionalism (Conway & Cassel 2012; Miles et al. 2013; Updegraff Marketing 2013).

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Med Teach. 2015 Sep;37(9):850-5. doi: 10.3109/0142159X.2015.1045856. Epub 2015 Jun 15.

Globalisation, economics and professionalism.

Tan CH1, Macneill P2.

Author information

• 1a National University of Singapore , Singapore .
• 2b University of Sydney , Australia.

Abstract

This paper presents an analysis of the effect of globalisation and attendant economic factors on the global practice of medicine, medical education, medical ethics and medical professionalism. The authors discuss the implications of these trends, citing case scenarios in the healthcare insurance, medical tourism, pharmaceutical industries, and the educational systems as well as in clinical practice, to illustrate the impact of globalisation andeconomics on professionalism. Globalisation, on the one hand, offers benefits for the global practice of medicine and for medical education. On the other, globalisation can have negative effects, particularly when the main driver is to maximise profitability across national boundaries rather than concern for human well-being. Appraising the effect of globalisation on professionalism involves assessing its effects at the intrapersonal, interpersonal, and institutional levels, and its effect on society at large.

PMID:

 

26075950

 

[PubMed - in process]