글로벌 의사 만들기: 무언가 해야 할 시간?(Med Teach, 2011)

글로벌 의사 만들기: 무언가 해야 할 시간?(Med Teach, 2011)

Developing a global health practitioner: Time to act?

JUDY MCKIMM1 & MICHELLE MCLEAN2

1Swansea University, UK, 2United Emirates University, UAE

“여전히 대다수의 의과대학 교육과정에 인간의 건강을 전 지구적 차원에서 바라볼 수 있게끔 하는 교육은 거의 부재하다. 그러나 전 세계가 가까워지는 미래 진료 환경에서 집단간의 갈등, 빈곤, 환경 파괴 등이 건강에 미치는 영향을 이해하는 것은 의사들에게 필수적이다.”

To consider the health of humanity on a global scale is rarely part of the medical curriculum, yet understanding the health effects of conflict, damage essen- poverty and environmental is tial for doctors practising in our shrinking world (Anon).

국제화와 세계화는 의학교육과 고등교육에서 흔히 사용되는 용어이다.

Globalisation and internationalisation, words commonly used in medical and higher education,

적절한 의료의 제공을 위해서 의학교육기관은 글로벌하게 사고하면서 로컬하게 행동할 수 있는 의사를 양성해야 한다. 또한 이들은 어디서 의료를 하든 지역사회와 인구의 변화하는 요구에 따를 수 있어야 한다.

Institutions should thus be producing medical graduates who can think globally but act locally to deliver appropriate healthcare and adapt to the changing needs of communities and populations, irrespective of where they practice medicine – a global health practitioner.

글로벌 의료인력은 무엇을 생각할 수 있어야 하는가?

What should a global health practi- tioner need to be aware of?

작아진 지구: 상호연결된 글로벌 커뮤니키

A shrinking world: An interconnected global community

우리가 사는 지구는 점점 더 좁아지고 있다.

The world in which we live is shrinking,

지금의 학생은 Net Generation의 '디지털 네이티브'라고 할 수 있으며, 멀티미디어와 함께 자라나고 정보에 즉각적 접근이 가능하다. 

Our students are the‘digital natives’ of the Net Generation, having grown up with multimedia and instant access to information (Morris & Kanter (2008) McKimm 2009). suggests that for today’s student:

컴퓨터라는 것을 통해서 보자면, 디지털 네이티브는 어떤 장소에서든 볼 수 있고, 어떤 사람과도 연결될 수 있으며, 어떤 개념에 대해서도 정보에 접근할 수 있다. 그들은 마치 이곳이 자신들의 방인 양 살고 있으며, 다니는 곳은 세상의 모든 곳이고 모든 기록된 역사이다. 

By looking through a computer window, they are able, instantaneously, to see almost any place, to connect to almost any person, and to access infor- mation about almost any concept... The space in which they move around, as if it were their own room, is the entire world and all recorded history (p. 115).

Kanter는 '상호연결성'이란 느낌이 강화되면서 학생들과 졸업생이 다른 문화권에서의 경험을 더 의도적으로 찾아나서고 있다.

Kanter (2008) believes that it is this feeling of enhanced connectedness on a global scale – the sense of global community that leads students and graduates to deliberately seek educational experiences to enrich their understanding of the practice of medicine in other cultures.

글로벌 헬스: 국제적 이슈

Global health: An international issue

이 '상호연결성'이라는 개념으로부터 국제보건이라는 개념이 등장했고, 협력적 행동으로 최선의 대응이 가능한, 국가 경계를 넘어는 보건 이슈가 등장했다. 국제보건 문제를 예상하고, 예방하고, 개선하기 위한 싸움에 참여하지 못하는 것은 건강 영역에서 미국의 지위는 물론 자기 자신의 보건, 경제, 안보까지 위험에 빠뜨릴 것이다.

Emerging from this ‘connectedness’ is the notion of global health – health issues and concerns that transcend national boundaries which are best be addressed by co-operative actions (United States Institute of Medicine 1997) – The failure to engage in the fight to anticipate, prevent, and ameliorate global health problems would diminish America’s stature in the realm of health and jeopardise our own health, economy,and national security (p. 4). 

기후변화, 갈등, 건강불평등

Climate change, conflict and healthcare disparities

환경 문제, 특히 기후 변화는 건강 불평등을 더 악화시킬 것이다. 

Environmental issues, climate change in particular, will further widen healthcare disparities. The health consequences of climate change include 

• compromised food security through flooding and droughts in an already sensitive agricultural sector, 
• increased mortality from extreme weather events, 
• water scarcity during droughts, 
• diarrhoeal diseases during flooding and 
• the spread of infectious diseases due to changing patterns of insect vectors (World Health Organization 2008).

Costello 등은 기후변화가 21세기 국제보건의 가장 큰 위협이 될 것이라 했다.

Costello et al. (2010) believe that climate change has been the greatest global health threat of the twenty-first century,

개발기구의 원조 대부분은 빈곤문제를 완화시키고, 강건한 보건 인프라 구축을 통해서 핵심 건강 이슈 - 만성질병, 감염병, 모자보건 - 를 해결하는 데 있다. 이러한 행동의 중심에는 적절하게 수련받은 보건의료인력이 있다. 태평양 국가와 같은 여러 나라에서 '효과적인' 보건의료인력은 그 지역에서 수련받은 의료전문직과, 지역사회/토착 보건인력, 보다 일시적이긴 하나 해외에서 온 의료전문인력의 팀으로 구성된다.

Much of the work of aid and development agencies focuses on alleviating poverty and establishing a robust health infrastruc- ture and adequate resources to address key health issues such as chronic and communicable diseases and maternal and child health (WHO 2007). Central to such activities is an appropri- ately trained health and community workforce. In many countries (for example in the Pacific islands), an ‘effective’ health workforce comprises a team of locally trained health professionals, community and indigenous health workers as well as a more transitory group of overseas-trained health professionals (Bedford & Hugo 2008).

글로벌 질병부담

Global burden of disease

Murray와 Lopez의 '글로벌 질병부담'을 업데이트 하면서 Mathers와 Loncar는 2020년에는 감염질환으로 인한 사망과 5세미만 사망자는 더 줄겠지만, 예방가능한 질병(주로 흡연과 관련한)들이 HIV/AIDS, 우울, 협심증, 차 사고 등보다 더 많은 사망자를 낼 것으로 예측했다. 교육과 의료는 이러한 사망을 예방해야 한다.

In their update of Murray and Lopez’ (1996) Global Burden of Disease study, Mathers and Loncar (2006) predict that in 2020 while fewer children under 5 years will die and deaths from communicable diseases will decrease, preventable diseases (many tobacco-related) will claim more lives than HIV/AIDS, depression, ischaemic heart disease or road traffic accidents. Education and access to healthcare are therefore vital for preventing such deaths (Mathers & Loncar 2006).

힘을 얻는 글로벌 사회적 책무성

Global social responsibility and accountability gaining momentum

1990년대 이후, 의학교육자들은 의학교육의 사회적 책무성을 더 강조했다.

Since the 1990s, medical educationalists have been promoting socially accountable medical education (Woollard 2006; Boelen & Woollard 2009). Social accountability has been described as:

의과대학은 교육/연구/진료활동을 통해서 지역사회, 지역, 국가의 건강과 관련된 우선순위 문제를 먼저 해결해야 한다. 우선적 건강문제는 정부/보건기관/보건전문가/대중 등이 협력해서 밝혀야 한다.

the obligation of medical schools to direct education, research and service activities towards addressing the priority health concerns of the community, region or nation that they are mandated to serve. The priority health concerns are to be identified jointly by governments, healthcare organizations, health pro- fessionals and the public (Boelen & Heck 1995, p. 3).

WFME의 기본기준에도 의학교육-진료-보건시스템의 연관성을 강조한다.

A WFME (2003) basic standard reflects a linkage between medical education, medical practice and healthcare systems.

WFME는 특히 local, national, regional and global contexts에 관심을 둘 것을 강조한다.

The WFME (2003) specifically states that attention should be paid to local, national, regional and global contexts.

글로벌 의사 양성의 장애물

Challenges of producing a global health practitioner

의학교육의 글로벌 불평등

Global disparities in medical education

26개의 SSA 국가는 의과대학이 없거나 1개 있고, 24%의 질병부담은 아프리카에 있으나, 3%의 인력만이 이 곳에 있다. 더 부유한 국가에는 의학교육에 대한 접근권에 격차가 있는데, 20%의 미국 의과대학생만이 하위 60% 출신이다.

That 26 sub-Saharan African countries have none or one medical school only and that Africa carries 24% of the world’s disease burden but only 3% of the global work healthcare force (Mullen et al. 2010),highlights the disparities in health education and healthcare.Disparities in access to medical education also exist in more affluent nations – only 20% of US medical students originate from families in the lowest three quintiles (AmericanAssociation of Medical Colleges 2005). 

교육과정에 대한 지역사회 참여 부족

Lack of community engagement in curricula

의과대학의 미션선언문, 비전선언문, 진급과 테뉴어 가이드라인, 행정구조에 지역사회-참여 학술활동를 얼마나 포함하고 있는가 대한 최근 북미 의과대학 설문 결과를 보면, 그 격차가 크게 들어난다. 많은 의과대학이 여전히 자신이 속한 지역사회를 포용하겠다는 개념을 포함하고 있지만, 글로벌 사회에 대한 책임에 대해서는 얼마나 기대할 수 있는가? ICRAM은 질병부담이 높아지고, 빈곤, 글로벌화, 혁신 등이 늘어나는 이 시기에, 대학의학이 글로벌 사화에 대한 책임을 인식하지 못하고 있다고 지적했다.

A recent survey of North American and Canadian medical schools, however, highlights significant gaps in the integration of community-engaged scholarship into medical school mission and vision statements,promotion and tenure guidelines and administration structures(Goldstein & Bearman 2011). With many medical schools still to embrace the notion of serving their own local communities,how feasible is it to expect a global social responsibility? The International Campaign to Revitalise Academic Medicine notes that at a time of increasing health burden, poverty, globali-sation, and innovation, academic medicine seems to be failing to realize its potential and global social responsibility(Clark 2005, p. 101). 

다국가 사업이 된 의료전문직 교육

Health professions education: An international business

세계적으로 의료전문직에 대한 요구를 충족시키기 위해서 해외 국가에서 간호사나 의사를 수입하는 경우가 늘고 있다. 또는 교육과정이나 전체 의과대학이 해외로 나가기도 하는데 Weill Cornell medical school in Qatar 가 그 사례이다. 그런데, 여기서 교육받은 학생은 어느 사회를 위한 의사인가?

The worldwide demand for healthcare professionals has culminated in many medical and nursing colleges producing graduates for other countries (e.g. India and the Philippines), whereas in other contexts, curricula have been bought or entire medical schools have been off-shored, the Weill Cornell medical school in Qatar being an example (Hodges et al. 2009). It is, however, pertinent to ask for which communities are these students being trained?

미래의 글로벌 의료인력 양성

Developing tomorrow’s global health practitioner

문화적 역량

Cultural competence

너무 오랫동안 'medical culture'는 서구의 문화를 의미해왔다. 그러나 이러한 ethos는 졸업생이 국가의 경계를 넘나들어 'think globally but act locally'해야 하는 상황에서 바뀌고 있다. WHO와 UN은 건강권에 대해서 문화적으로 적합한 의료시스템에 대한 접근권이라고 했다. Stout과 Downey는 여기에 여러 형태의 치료 (전통치료, 치료행위) 가 포함된다고 했다. McKimm은 문화적 요인에 기인하는 의료 불평등은 여러 수준 -사회/기관/전문직/개인 간 - 에서 나타난다고 주장했다.

For too long, ‘medical culture’ has meant Western culture. This ethos is, however, changing with the increasing recognition that graduates need to cross cultural boundaries and to ‘think globally but act locally’ (Taylor 2003). The WHO and United Nations declarations on the right to health encompass access to a culturally appropriate healthcare system, which, for Stout and Downey (2006) includes access to different forms of treatment (such as traditional medicine or healing practices). McKimm (2011) asserts that inequalities in healthcare result- ing from cultural factors may need to be addressed at many levels: societal, organization, professional and interpersonal (p. 56).

건강은 여전히 '사회적'인 것이다

Health remains ‘social’: Advocacy

건강상태는 의료/정치/경제/교육/환경 등 여러 요인의 상호작용에 따라 결정된다.

Health status is determined by the interrelationship of many factors: medical, political, economic, educational and environ-mental, the bases of the current global health inequalities(Evert et al. 2008; Boelen & Woollard 2009). 

Woollard는 21세기에 '역량을 갖춘 의사'란 상당한 다른 사람에게 ethos of service를 전달할 수 있는 사람, 즉 사회적, 환경적 정의의 지지자가 되어야 한다고 했다. Woollard는 Boyer의 네 개의 scholarship과 함께(teaching, discovery, integration, application) 학문 참여의 중요성을 강조했는데, 이를 통해서 사회적/시민적/환경적/윤리적 문제를 해결해야 한다고 했다.

For Woollard (2006), the twenty-first century brings the challenge of not only creating skilled and competent graduates but practitioners who are capable of transmitting a profound ethos of service to the welfare of others (p. 302) – advocates of social and environ-mental justice. Woollard (2006) also emphasises the impor-tance of promoting the scholarship of engagement, alignedwith Boyer’s other four scholarships (teaching, discovery,integration, application) in order to understand and address pressing social, civic, environmental and ethical problems facing communities across the world. 

글로벌 핵심 교육과정

A global core curriculum

글로벌 의료인력 양성: 핵심 이슈

Developing a global health practi-tioner: Key issues 

의학교육의 변혁

Transformation of medical education

GIC는 제3세대 교육 변화를 이야기했다.

A Global Independent Commission proposes a third generation of reform:

모든 나라의 건강전문직은 지식을 동원할 수 있어야 하고, 비판적 추론을 할 수 있어야 하고, 윤리적 행동을 할 수 있어야 한다. 이를 통해서 locally responsive, globally connected team으로서 환자와 인구집단 중심의 건강시스템에 참여할 수 있어야 한다.

All health professionals in all countries should be educated to mobilize knowledge and to engage in critical reasoning and ethical conduct so that they are competent to participate in patient and population-centred health systems as members of locally responsive and globally connected teams (p. 33). 

GCSAMS는 의과대학이 건강한 의료시스템은 튼튼한 일차의료적 접근 위에 세워져야 하며, 1차의료가 2차, 3차 의료와 적ㅈ러한 균형을 이뤄야 한다고 했다.

The Global Consensus for Social Accountability of Medical Schools (GCSAMS 2010) recently advocated that medical schools recognise that a sound health system is founded ona solid primary healthcare approach, with proper integration of the first level of care with secondary and tertiary levels and an appropriate balance of professional disciplines to serve people’s needs

개개 의사들은 유능할 수 있으나, 이 전문성이 다-전문가 팀에서 통합되어 효과적인 환자-중심, 인구-기반 의료를 제공할 수 있어야 한다.

While individual professions have distinctive and perhaps complementary skills, it is imperative that this expertise coalesces such that multiprofessional teams are effective inpatient-centred and population-based health care (Frenk et al.2010). 

이는 WHO의 FCIE와도 일치하는 것이다.

This view is echoed Practice in and the WHO’s Framework for Collaborative Interprofessional Education(WHO 2010) which emphasises the need for health profes-sions’ education to produce a practice-ready workforce able to work flexibly and collaboratively in a range of contexts, cultures and countries to improve health outcomes.

지역의 요구에 부응하며 동시에 국제보건 강조하기

Promoting global health while meeting local needs

협력과 네트워크

Collaboration and networks

(a) Academic collaborations: faculty and student exchange;student electives or in-service learning (often in devel-oping countries); research; complementary degree and graduate programmes and education and health networks (e.g. Towards Unity for Health (TUFH)http://www.the-networktufh.org/home/index.asp; FAIMER (the Foundation for the Advancement of Research,International Medical Education and www.faimer.org). 

(b) Philanthropic organisations: e. g. the Gates and Kellogg Foundations which provide funding for health education and training initiatives (Philibert 2009). 

(c) Partnerships with communities, governments, development agencies: establishing new medical schools in partner countries; working with local communities on health projects and consultancy on aid-funded education and training projects. 

Conclusions and next steps

사회적책무성은 소수의 주변부 관심에서 의과대학의 당연한 핵심 이슈로서 그 자리를 옮겨왔다고 Woollard가 믿었으나, 만약 우리가 글로벌 의사를 양성하려면, 이러한 과정을 더 가속화하여 각 교육기관이 더 책임감을 갖게 해야 한다. Boelen and Woolllard은 의학교육기관이 질/평등/관련성/효율성의 기본 원칙에 충실함으로써 사회에 미치는 영향을 보다 뚜렷하게 하고, 건강시스템 발전에 적극적으로 참여하는 근거를 제공해야 한다고 했다. 건강전문직에 있어서 사회적 책무성은 세 가지 상호의존적 영역으로 측정해야 한다.

While Woollard (2006) believes that social accountability is moving from the peripheral concern of a few to its rightful place as a central issue of medical schools, if we are serious about producing global health practitioners, we need to accelerate the process and make institutions more account-able. Boelen and Woolllard (2009) propose that educational institutions should be required to verify their impact on society by following basic principles of quality, equity, relevance and effectiveness and by providing evidence of active participation in health system development. Social accountability should then be measured in three interdependent domains concern-ing health professionals: 

• 개념화: 교육기관의 역할 conceptualisation (role of the institu-tion), 
• 생산: 바람직한 전문직 production (in terms of the desired professional) and 
• 활용성: 사회적 요구 충족 utilisability (needs of society addressed). 

Woollards의 책임감 있는 아카데믹 파트너십의 위계에도 global을 넣어야 한다. (Municipal, local, national)

Woollard’s (2006) hierarchy of responsible academic part-nerships (e.g. municipal, local, national) should also include‘global’. 

Boelen C, Woollard B. 2009. Social accountability and accreditation: A new frontier for educational institutions. Med Educ 43:887–894.

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Med Teach. 2011;33(8):626-31. doi: 10.3109/0142159X.2011.590245.

Developing a global health practitioner: time to act?

McKimm J1, McLean M.

Author information

• 1College of Medicine, Swansea University, Grove Building, Singleton Park, Swansea SA2 8PP, Wales, UK. j.mckimm@swansea.ac.uk

Abstract

Although many health issues transcend national boundaries and require international co-operation, global health is rarely an integral part of the medical curriculum. While medical schools have a social responsibility to train healthcare professionals to serve local communities, the internationalisation of medical education (e.g. international medical students, export of medical curricula or medical schools) makes it increasingly difficult to define it as 'local'. It is therefore necessary to produce practitioners who can practice medicine in an ever-changing and unpredictable world. These practitioners must be clinically and culturally competent as well as able to use their global knowledge and experience to improve healthand well-being, irrespective of where they eventually practice medicine. Global health practitioners are tomorrow's leaders, change agents and members of effective multiprofessional teams and so need to be aware of the environmental, cultural, social and political factors that impact onhealth, serving as advocates of people's rights to access resources, education and healthcare. This article addresses some of the difficulties ofdeveloping global health practitioners, offering suggestions for a global health curriculum. It also acknowledges that creating a global healthpractitioner requires international collaboration and shared resources and practices and places the onus of social accountability on academic leaders.

PMID:

 

21774648

 

[PubMed - indexed for MEDLINE]