양질의 진료를 보장하기: 인증(대학), 면허, 증명, 재확인의 역할 (Med Educ, 2014)

양질의 진료를 보장하기: 인증(대학), 면허, 증명, 재확인의 역할 (Med Educ, 2014)

Ensuring high-quality patient care: the role of accreditation, licensure, specialty certification and revalidation in medicine

John Boulet & Marta van Zanten

도입

INTRODUCTION

의료 규제 담당자의 관점에서, 불량한 의사는 질병에 비유될 수 있다. 규제의 첫 번째 역할은 역량을 갖춘 자에게만 전문적 진료를 제한하여 환자안전을 보장하는 것이다. 유사하게, 잘 기능을 수행하는 인증 시스템은 역량을 갖추지 못한 의사의 양성을 최소화시킬 수 있다.

From the perspective of medical regulators, disease can be thought of as a metaphor for poorly functioning doctors. The primary mandate of regulators is to ensure patient safety by restricting professional practice to only those who have demonstrated competence (i.e. are free from ‘disease’). In a similar way, properly functioning accreditation systems should minimise the production of poorly skilled doctors by improving the education process. Prevention, in this context, is certainly preferable to cure. Given the costs associated with poor health care delivery, it is better to produce highly competent practitioners and ensure, through continuing educational activities, that those who care for patients remain competent to do so.

인증

ACCREDITATION

인증 시스템은 stakeholder에게 기본의학교육과정과 이후 수련 프로그램의 퀄리티를 보증하는 효과적인 기전으로 인식되어 왔다. 인증은 designated authority가 주기적으로, 기관의 교육 프로그램을, 특정 준거와 절차에 따라, 검토하고 평가하는 것을 말한다.

Systems of accreditation are frequently viewed by stakeholders (e.g. the public, health care administra- tors, policymakers) as effective mechanisms for ensuring the quality of basic medical education cur- ricula and subsequent training programmes across the learning continuum. Accreditation can be defined as a process by which a designated authority reviews and evaluates, on a cyclical basis, an educa- tional programme or institution using clearly speci- fied criteria and procedures.

전 세계 다양한 조직에서 의학교육과 수련 프로그램 인증을 해왔다. 많은 국가에서, 예를 들어 남아메리카의 대부분, 아프리카와 아시아의 일부에서 인증 기관은 고등교육기관 전체에 대한 검토를 한다. 일부 국가(호주, 멕시코, 영국) 등에서는 의학과 같은 전문직교육프로그램에 특이적인 기관이 별도로 존재한다.

Various organisations around the world accredit medical education and training programmes. In many countries, such as the majority in South America and some in Africa and Asia, accreditation organisations review higher education institutions as a whole. In other countries (e.g. Australia, Mexico, the UK), specialised agencies accredit specific pro- fessional education programmes, such as medicine.

인증기구는 정부기관(MOE, MOH)의 한 부분일 수도 있고 독립된 기구일 수도 있다. 인증기구의 결정은 보통 공식적으로 정부 단위에서 인정된다. provincial, national, cross-national 수준에서 작동할 수 있으며, 평가는 의무적일 수 있고 자발적일 수도 있다. 인증기구의 권위는 모든 의학교육프로그램을 포괄할 수도 있고, 일부에 대해서만(공립 또는 사립) 시행할 수도 있고, 특정 언어를 사용하는 기관에 대해서만 할 수도 있고, 다른 정책요건에 따를 수도 있다.

Accreditation authorities can be part of a country’s government, such as an entity that is directly part of a ministry of education or health, or may be an independent body, the decisions of which are usually officially recognised at government level. Organisations can function at the provincial, national or cross-national (regional) level, and reviews can be mandatory or voluntary. An accreditation organisation’s authority can be broad and encompass all medical education programmes in its jurisdiction, or be limited in scope, and cover only either public or private educa- tion programmes, institutions with a specific lan- guage of instruction, or institutions that meet certain other policy requirements.

미국의 인증시스템

Accreditation in the USA

LCME와 COCA

In the USA, the Liaison Committee on Medical Education (LCME) is the nationally recognised accrediting authority for medical education pro- grammes leading to the MD degree in US and Cana- dian* medical schools, and the Commission on Osteopathic College Accreditation (COCA) accred- its schools granting the osteopathic (DO) degree.

ACGME와 AOA. 2015년부터는 단일한 통합된 시스템을 운영할 것.

Currently, the Accreditation Council for Graduate Medical Educa- tion (ACGME) is the overseeing body responsible for the quality assurance of allopathic GME, and the American Osteopathic Association (AOA) accredits osteopathic residency programmes. These organisa- tions have recently announced that, as of 2015, there will be a single, unified accreditation system for GME programmes in the USA.5

ACGME는 여섯 개 역량. 

The ACGME has identified six general competencies deemed essential for residency training: patient care; medical knowledge; practice-based learning and improvement; interpersonal and communication skills; professionalism, and systems-based practice. A meta-analysis of 56 studies reported mixed results, with the authors concluding that there was little evidence that most of the cur- rent measurement tools validly assessed the compe- tencies independently of one another.6

인증 (글로벌)

Accreditation globally

FAIMER에 의해 유지되는 DORA는 177개국 중 기본의학교육 인증시스템을 갖춘 104개 국가의 목록을 열거하였다. 이 중 42%는 의학교육 특이적 인증기구, 58%는 고등교육기관의 일부로서 의학교육프로그램을 인증하는 기구를 가지고 있다. 인증시스템이 존재한다고 해서 모든 해당 국가의 의과대학이 인증 절차를 밟는 것은 아니다.

As of February 2013, the Directory of Organizations that Recognize/Accredit Medical Schools (DORA) maintained by the Foundation for Advancement of International Medical Education and Research (FAIMER) lists 104 countries with active systems of accreditation for basic medical education (out of 177 countries with currently operational medical schools).7 Of these countries, 42% (n = 44) have accreditation agencies that are specific to medical education, and 58% (n = 60) use agencies that accredit medical programmes as part of higher edu- cation institutions. It is important to note that the existence of an accreditation system in a country does not denote that all medical schools in that country are accredited, as the review is sometimes voluntary.

1996년 WHO의 설문에서 2/3의 의과대학이 외부기구에 의한 인증을 받는다고 하였다.

A report based on a 1996 World Health Organization (WHO) survey of ministries of health and deans of medical schools8 indicated that almost two-thirds of medical schools were accredited by an external body,

또 다른 국제적 investigation은 비록 절반 이상의 국가에서 인증시스템을 갖추고 있지만, authority와 enforcement의 수준은 차이가 크다.

Another global investigation of medical education accreditation found that although over half of all countries with medical schools have a national system of accreditation, the nature of the various authorities and levels of enforcement vary considerably.9

아홉 개 개발도상국의 의학교육 인증시스템을 비교한 연구에서 일부 개발도상국에서 robust quality assurance procedure가 퍼져나가고 있으며, 그 프로토콜은 미국과 비슷하다. 인증시스템의 prevalence와 특징에 대한 문헌은 있으나, 그것이 교육향상에 기여하는 유용성을 정량화한 근거는 거의 없다.

A study comparing medical education accreditation systems in nine developing countries located throughout the world concluded that the trend towards instituting robust quality assurance procedures was spreading to some developing countries, in which protocols similar to those used in the USA have been developed and implemented.10 Unfortunately, although the preva- lence and characteristics of accreditation systems have been documented, there is relatively little evidence to quantify their utility with respect to improving education practices.

인증시스템의 타당도

Validity of accreditation

인증의 가치에 대한 연구가 부족하다는 것은 교육분야에 걸쳐 적용가능한 방법론적 요인이 다수이기 때문일 수 있다. 예컨대 의학교육에 있어서 많은 국가에서 모든 프로그램이 인증을 받기 때문에 국가 내에서의 비교가 불가능하다.

The lack of research related to the value of accreditation is likely to reflect a number of methodological fac- tors applicable across educational fields.11,12 For example, in medical education specifically, in many countries all programmes are accredited (usually based on the same criteria), which precludes within- country comparisons of performance of students or graduates from accredited and non-accredited pro- grammes.

이러한 방법론적 어려움에도 불구하고, 일부 연구자들은 인증활동이 의학교육을 발전시키고, 적어도 학생의 퍼포먼스 차원에서 그러함을 보여주었다.

Despite these methodological difficulties, some investigations have shown that accreditation activi- ties may improve medical education, at least in terms of the performance of students. 

• In a study of Mexican and Philippine citizens seeking Educa- tional Commission for Foreign Medical Graduates (ECFMG) certification, first-attempt pass rates on all components of the required US Medical Licensing Examination (USMLE) series were higher for individuals who had attended accredited medical schools, compared with their peers who had attended non-accredited schools.13 

• In another study of the performance of all graduates of international medical schools who took the USMLE Step 2 clini- cal skills (CS) examination during the 5-year (2006– 2010) study period, accreditation was positively asso- ciated with the Step 2 CS first-attempt pass rate.

비록 이들 연구가 인증활동과 학생의 시험성적에서 연관성을 보여주었지만, 퀄리티에 대한 또 다른 표지자가 필요하고, 여기에는 이후 커리어에서 치르게 되는 시험과 실제 환자 진료 데이터 등이 필요하다. 이런 것 없이는 인증 프로세스가 좋은 것appreciable인지 알기 어렵고, 교육프로그램에 대한 장기 영향력도 알기 어렵다.

Although these studies include some data showing a positive association between accreditation activities and student success on examinations, additional markers of quality, including performance on other examinations taken later in the career and actual patient care data are required. Without these, it is difficult to know whether accreditation processes have an apprecia- ble, long-term impact on education programmes and, hence, the quality of those who graduate and eventually practise medicine.

인증시스템의 존재에 따른 영향력 자료를 수집하는 것 외에도, 인증의 요소(구체적 스탠다드)를 조사하는 것도 필요하다. 지금까지의 연구가 인증시스템의 존재 여부 혹은 일부 일반적 특성에 관해 진행되어왔다면, 소수의 연구만이 특정 의학교육 스탠다드의 적절성 또는 효과성에 대해서 다루었을 뿐이다.

In addition to gathering data on the effects of the existence of accreditation systems, it is also impor- tant to investigate the components of accreditation, such as the specific standards used and protocols employed, that may enhance the quality of the edu- cation process.15 Whereas previous investigations focused on describing the existence and some gen- eral characteristics of accreditation systems, only a few studies, to our knowledge, have compared or assessed the effectiveness or appropriateness of the specific medical education standards used to make accreditation decisions.16–18

제한적이더라도 근거는 존재하재하고, BME에서 인증의 가치를 지지한다. 의과대학은 자신의 QA system을 돌아보고 internal rules and regulations와의 compliance를 정해야 한다.

Although there is evidence, albeit limited, to sup- port the value of accreditation of basic medical education programmes, some benefits of these sys- tematic reviews may be manifest despite limited data showing marked improvement in student outcomes. Schools must examine their own quality assurance systems and determine their compliance with internal rules and regulations.

인증기구에 의한 인증 결정은 이해관계자들에게 유의미하고 신뢰할 수 있는 것으로 받아들여진다. 그러나 절차의 투명성 부족, 방법론적 변동성, 학교 간 표준화 부족 등으로 인해서 그 결정은 의심을 받거나 자의적인 것으로 보이기도 한다. 전세계적으로 받아들여지는 시스템을 갖추기 위해서 WFME는 FAIMER와 함께 인증기구를 recognition하는, 즉 meta-accreditation 절차를 만들고 있다.

Accreditation decisions made by agencies around the world are usually considered credible and are accepted by stakeholders as meaningful and trust- worthy. Nevertheless, because of a lack of transpar- ency in the process, variability in methodology, or other issues related to a lack of standardisation across schools, the decisions can sometimes appear capricious and arbitrary. In order to address the need for a globally accepted system for ensuring the quality of accreditation systems themselves, the World Federation for Medical Education (WFME), in conjunction with FAIMER, has formulated poli- cies and procedures for the recognition of agencies accrediting medical schools, an endeavour in meta- accreditation.19

인증에 대한 인센티브

Incentives for accreditation (cost/benefit)

미국에서, BME에 대한 인증은 기본적으로 자발적인 것이지만, 졸업생이 GME에 들어가고 진료면허를 받기 위해서는 그 학교가 인증을 받아야 한다.

In the USA, the accreditation of basic medical education programmes is techni- cally voluntary, but a school must be accredited in order for graduates to enter GME and obtain licen- sure to practise, 

• For example, in Mexico, students at accredited schools are provided with enhanced clinical clerkship opportunities compared with their peers at non- accredited institutions. The purpose of the US Department of Education National Committee on Foreign Medical Education and Accreditation (NCFMEA) is to review the standards used by for- eign countries to accredit medical schools and determine whether those standards are comparable with standards used to accredit medical schools in the USA.20 Thus, medical schools located outside the USA that seek to attract US citizen students are given incentives to seek accreditation by an agency that has been deemed comparable by the NCFMEA.

인도 사례

In other countries, such as India, obtaining accredi- tation by a voluntary agency (e.g. the National Assessment and Accreditation Council [NAAC]) in addition to the mandatory accreditation by the Med- ical Council of India (MCI) carries some prestige in a crowded field of medical education programmes. A school considering voluntary accreditation needs to weigh the direct cost of seeking the accreditation review and the costs associated with making the nec- essary changes dictated by the standards against the indirect value of obtaining a secondary accreditation status.

의사의 유동성

Doctor mobility

의학교육 인증은 의사의 유동성에도 도움이 된다. 왜냐하면 하나의 기관으로부터 여러 의과대학이 인증을 받거나, 다수의 기관으로부터 상호 인정을 받으면 학생들이 의과대학 간 학점 교류와 같은 유동성 옵션이 생기기 때문이다. 

Accreditation of medical education can also aid in doctor mobility, as accreditation of multiple schools by a common agency, or mutual recognition of accreditation decisions across multiple agencies, can enhance options for student mobility between schools, such as the transfer of credits.

면허, 증명, 재인증

LICENSURE, CERTIFICATION AND REVALIDATION OF CREDENTIALS

의학에서, 적어도 대부분의 국가와 사법권에서 합리적으로 진료를 제한하는 것이 있다. 면허 - 대체로 정부에 의해서 교부되는 - 는 국가 혹은 지역 단위에서 최초에 그 전문직군으로 들어가기 위해 필요한 것이다. 증명은 반대로 비-정부 기관에 의해서 부여되며, 일반적으로 더 높은 수준의 자격qualification을 함축한다. 전 세계 많은 지역에서 의사는 진료를 위한 최초의 면허를 받을 수 있고, 그 후에 전문과목의 학회나 보드에서 증명을 받는다.

In medicine, at least in most countries and jurisdic- tions, there are reasonably strict practice regula- tions. 

• Licensure (or registration), which is generally granted by governments, at either the national or regional level, is necessary for initial entry into the profession. 

• Certification, by contrast, is usually con- ferred by a non-governmental agency, and typically connotes a higher level of qualification. 

In many areas of the world, a doctor can obtain an initial licence to practise medicine and then specialise, obtaining a certificate from a specialty society or board.

Licensure와 Certification이 각국마다 다른 것처럼, Licensure와 Certification에 관한 발급 결정도 상당히 다르다. 더 나아가 의학의 발전과 변화하는 환자 요구에 따라서 licensure와 certification 기준은 시간에 따라 변할 수 있고, 또 그래야 한다. 일반적으로 Licensure와 Certification은 어떤 형태의 credentialing과 assessment를 포함한다. 면허 발급을 위한 credentialing으로 다음의 것이 필요하다.

Just as licensure and certification processes vary around the world, the criteria upon which licensure and certification decisions are granted can be quite different.21–23 Moreover, to keep up with advances in medicine and changing patient needs, licensure and certification criteria can, and should, be modi- fied over time.24 In general, licensure and certifica- tion involve some form of credentialing and assessment. 

For licensing purposes, credentialing can entail, amongst other criteria, 

• confirmation of medical school attendance and graduation, 

• recogni- tion of the medical school (e.g. accreditation), and 

• verification of the medical school diploma. 

Credentialing에 더하여, 모두는 아니더라도 Licensure와 Certification 기구는 일정 유형의 평가 프로세스가 있다. Credentialing와 Assessment 프로세스 모두 Licensure와 Certification을 받고자 하는 지원자들이 특정 기준을 만족시켰는지를 확인하고, 대중을 qualify되지 않은 진료행위에서 보호하고자 하는 목적으로 설계된다.

In addition to credentialing, most, if not all, licensing and certifi- cation (or registration) bodies have some sort of assessment process. In the USA, initial licensure is dependent on successful completion of the USMLE or the Comprehensive Osteopathic Medical Licens- ing Examination (COMLEX-USA). Subsequent board certification (or registration) may also involvea number of assessments, including in-training examinations and specialty board examinations. Both the creden- tialing and assessment processes are designed to ensure that candidates seeking licensure and certifi-cation have achieved specific standards, and thus help to protect the public from unqualified practi- tioners. 

역사적으로, Licensure와 Certification은 한번 주어지면 평생 가는 것이었다. 그러나 이제는 MoL와 MoC를 강조하는 쪽으로 옮겨가고 있다. 영국 등에서는 이를 revalidation이라고 한다. 이러한 're-registration'은 일정 기간(5년 또는 10년)마다 이뤄지며, 여러가지 요소(CME, CPD, 동료평가, 환자평가, 시험 등)로 구성될 수 있다.

Historically, both licensure and certification (or reg- istration) have been granted for the lifetime of the doctor.2 Today, there is a general movement towards maintenance of licensure (MoL) and main- tenance of certification (MoC) requirements. In the UK and many other countries, this process is typi- cally referred to as revalidation. This ‘re-registration’ of doctors, which is typi- cally on a periodic schedule (e.g. every 5 or 10 years), can have many components, including requirements for continuing medical education (CME) or continuous professional development (CPD), peer and patient assessments, and various types of examination.

최근, 임상에 re-entry하는 들어서는 의사들에 대한 규제에 대한 논의가 있다. 여기서 논의의 중심은 '해당 전문직을 자발적이든, 규제에 따라서든 떠났던 사람이 다시 전문직을 수행하기에 적절한가'이다.

Recently, there have been discussions of the regulatory challenges associ- ated with doctor re-entry into clinical practice.23,28 Here, the impetus is to ensure that doctors who have left the profession, either voluntarily or because of disciplinary action, are fit to return.

비록 Licensure, Certification, Revalidation이 대부분의 국가에서 도입되어 있지만, 국제적으로 통용되는 best practice는 없다. 대신, 각 정부가 자신의 나름의 기준을 만들고 있다.그럼에도 불구하고 어떻게 도입되느냐 그리고 구체적은 기준이 얼마나 엄격rigour하느냐에 따라서 이들은 긍정적 결과를 낳을 수도 부정적 결과를 낳을 수도 있다.

Although licensing, certification and revalidation of doctors are accepted practice in most nations, there are no globally accepted ‘best practices’. Instead, local governments (or specialty societies) maintain their own standards. Never- theless, depending on its implementation and the rigour with which specified criteria are enforced, the application of licensure (or certification or reg- istration or revalidation) processes can have both positive and negative consequences.

Licensure와 Certification의 타당도

Validity of licensure and certification (scores and decisions)

가장 주된 우려는 평가와 실제 의료행위가 얼마나 match하느냐는 것이다. 면허를 위한 평가는 명확하게 환자가 의사에게 기대하는 역량을 반영해야 한다. 진료중인 의사들에게서 발견되는 문제의 성격과 유형이 규제를 위한 평가가 얼마나 요구되는지 알려준다. 종종, 내용 타당도를 지지하기 위해서 실제 진료 자료를 test blueprint에 활용한다. 그럼에도 불구하고 의료에는 다양한 측면이 있고(건강정보기술의 활용 등) 규제 프로세스에서 이것들이 더 잘 평가되어야 할 필요가 있다.

Of primary concern is the match between what is assessed and what doc- tors actually do in practice. Assessments for licen- sure should clearly reflect competencies that patients expect of their doctors.31 The assessment needs for regulation can also be informed by the nature and types of problems typically seen in prac- tising doctors.32 Often, to support content validity, actual practice data are used to help inform the test blueprint (i.e. how examination content is distrib- uted in a test form). Never- theless, there continue to be various aspects of medical care (e.g. the use of health information technology) that need to be better assessed as part of the regulatory process.33

면허시험이 relevant content를 담고 있다는 것을 보여주기 위한 많은 작업이 있었음에도, 새로운 시뮬레이션-기반 평가는 기존에는 평가하기 어려운 역량을 측정할 수 있다. 그러나 타당도 근거는 잘 해봐야 discouraging할 뿐이다. USMLE점수를 전공의 선발에 사용하는 validity에 대한 의문이 있었다. 그러나 면허시험점수와 졸업 후 수행능력은 validity chain에서 그저 하나의, 상대적으로 취약한 것일 뿐이다. 정말 필요한 것은 이들이 unrestricted 면허를 받았을 때 어떻게 하느냐이다. 안타깝게도 이러한 연구는 부족하고, 주로 관찰적/묘사적이며 인과간계 해석이 안된다. 반면, 증명(재증명)에 대해서 의료전문직 내에서의 advanced standing이 더 나은 환자진료와 관련이 된다는 연구가 있다.

Although much work has been conducted to ensure that licensure assessments contain relevant content, and new simulation-based assessment methods can measure certain competencies that were difficult to measure previously,34 other validity evidence is often lacking or, at best, discouraging. For example, in the USA, some researchers have questioned the validity of USMLE scores for making medical resi- dency selections.35 However, the relationship between these licensure assessment scores and post- graduate performance is only one, and probably a relatively weak, link in the validity chain. What is really needed is some indication of the quality of care these individuals provide after receiving an unrestricted licence to practise medicine. Unfortu- nately, the research evidence linking regulatory interventions and quality of care is sparse, mainly observational and descriptive, and does not, for the most part, allow for causal interpretations.36 By con- trast, with respect to certification (or recertifica- tion), there have been several studies to show that advanced standing within the medical profession (i.e. specialisation) is associated with the provision of better patient care.37–39 

초기 면허 발급에 대해서 보면 많은 연구들이 면허시험 점수가 미래의 진료 퍼포먼스와 관련됨을 보여주었다. 비록 이들연구가 informative하고 면허시험의 퍼포먼스가 미래의 진료까지 외삽가능함을 보여주지만, 아직 갈 길이 멀다.

For initial licensure, several studies have shown that licensure examination scores are related to future practice performance.42–44 Although these studies are infor- mative, and provide some evidence to suggest that performance on licensure examinations extrapo- lates to practice, they are far from complete.

새로운 평가를 Licensure와 Certification의 한 부분으로 도입하는 것이 가져올 영향은 클 것이다. 평가가 잘 만들어지고 실제 진료행위와 유의미하게 연결이 되어있다고 한다면, 지원자들이 시험을 준비하면서 더 나은 의사가 될 수 있을 것이다. 이러한 효과는 주로 CME에 근거를 두고 있으며, 재확인revalidation 활동에서 더 두드러질 것이다.

There is, no doubt, a consequential impact of intro- ducing new assessments as part of the licensure and certification (or registration) process.46 Provided that the assessments are well constructed and mean- ingfully related to practice, candidates will prepare, making them better practitioners. This effect, based primarily on CME, is probably more pronounced in revalidation activities.27,47

비용과 이득

Costs and benefits

대부분의 면허, 증명, 재인증 프로세스는 매우 비용이 많이 든다.

Most licensure, certification and revalidation pro- cesses are very expensive, and costs are typically borne by the candidate. As an example, the total cost of the USMLE (Step 1, Step 2 Clinical Knowl- edge, Step 2 Clinical Skills), necessary for licensure in the USA in all jurisdictions, is approximately US $2320.48 On top of the cost of typical licensure assessments, it is also com- mon to have a recurring fee associated with the granting and maintenance of the licence. For those doctors who seek specialty certification, there are additional expenses associated with obtaining and maintaining this status. Finally, with the possible introduction of simulation-based assessments for the MoC49 and retraining of doctors for medical licen- sure,50 the expense borne by the individual doctor is likely to rise. 

비록 면허, 증명, 재인증 비용이 엄두도 못 낼 정도로 높긴 하지만, 이것을 관리감독하는데 드는 비용은 그것이 없을 때 사회가 감당해야 하는 비용에 비추어 생각해보아야 한다. 규제시스템이 더 나은 의사를 양성한다는 일부 자료가 있다. 또한 전문과목학회specialty board의 증명과 등록이 더 나은 진료를 한다는 결과도 있다. 그러나 더 연구가 필요하다.

Although licensure, certification and revalidation costs can be prohibitive, the costs of oversight must be weighed against the potential cost of its lack to society (e.g. poor patient care). There are some data to show that regulatory (licensure) systems yield bet- ter performing doctors,51,52 and even more evidence linking specialty board certification or registration to better patient care,53–55 but there appear to be no comprehensive studies of their costs and benefits.

이 때 문제의 일부분은 개별 의사들의 poor care의 비용과 관련한 어려움을 반영할지도 모른다.

Here, part of the problemmay reflect the difficulty of relating the costs of (poor) care with the individually licensed doctor.

비용과 관련한 또 다른 문제는 의사의 qualification에 대한 정확한 DB를 구축하는 것이다. 미국과 다른 곳에서 이미 노력이 있어왔다. 규제시스템의 효과성을 판단하기 위해서 포괄적이고 종단적인 자료는 필수불가결한 것이다.

Another issue related to cost rests with the need to maintain accurate databases concerning doctor qualifi- cations. In the USA and elsewhere, efforts have been made to construct national practitioner databases.57 To judge the efficacy of any regulatory sys- tem, it is imperative to have comprehensive, longitudinal data on all doctors within a jurisdiction, including qualifications and practice characteristics.

의사의 유동성

Doctor mobility

개별 여행자들에 입장에서 외국에 도착하면 자동차를 빌리는 것은 당연한 절차이다. 국제운전면허증이 일부 국가에서 필요하지만, 차 대여 업체는 보통 그 대여 업체가 설립된 사법권 내에서 valid한 면허만 요구한다. 환자를 보는 것은 물론 운전보다는 더 복잡하지만, 의료의 국제화는 언젠가 authorities로 하여금 공동의 licensure pathway를 설립하게 할지도 모른다.

For individuals who travel, it is fairly straightforward to arrive at an airport and rent a car. Although international driver’s licences can be procured in some parts of the world, rental car companies typi- cally demand only a licence that is valid in the juris- diction in which the renter resides. Although treating patients is certainly more complex than driving a car, the globalisation of medicine, including the desires of patients to tra- vel across national borders to obtain health care, may one day motivate authorities to establish a com- mon licensure pathway.62,63

비록 유동성이 중앙화된 규제 기구에 의해서 강화될 수는 있지만 단점도 있다. 첫째로, 의료행위라는 것은 지역마다 다르다. 타당도 측면에서 광범위한 지리적 영역을 포함하는 단일화된 시험을 만드는 것은 어렵기도 할 뿐만 아니라 방어가능defensible하지 않을 수 있다. 만약 그렇다 하더라도, 여전히 면허기구들은 시험내용에 따라서는 best practice에 대해서 서로 공유할 필요가 있고, 그것이 효율적인 것이다.

Although mobility can be enhanced by the introduc- tion of centralised regulatory structures (e.g. national or international licensing examinations), there are some potential drawbacks. First and fore- most, the practice of medicine can be quite differ- ent from one region to another. Based on validity considerations, creating a unified examination (for licensure or certification) that spans a large geo- graphic region, or even a continent, may be quite difficult and, perhaps, not defensible. Even so, it would still be prudent, and efficient, for licensing authorities to share best practices and, when appli- cable, examination content.64

결론

CONCLUSIONS

그러나 미래의 환자 진료가 어떻게 되든, 역량의 진화는 필수적인 것이며, 적절한 규제는 자원(연구결과와 자료 등)의 공유 그리고 사용가능한 근거를 활용하여 best practice를 개발할 때 달성될 수 있다.

However, regardless of how patient care is deliv- ered in the future, or the evolution of competencies deemed essential for practice, the development of sound regulatory practices can be best accomplished by sharing resources, including research findings and data, and using the available evidence from around the world to develop best practices.

인증, 면허, 증명, 재확인의 성과를 정량화하기 위한 시스템이 필요하다.

Systems to evaluate and quantify the outcomes of accreditation, licensure, certification and revalidation programmes are needed.

9 van Zanten M, Norcini JJ, Boulet JR, Simon F. Overview of accreditation of undergraduate medical education programmes worldwide. Med Educ 2008;42: 930–7.

---

Med Educ. 2014 Jan;48(1):75-86. doi: 10.1111/medu.12286.

Ensuring high-quality patient care: the role of accreditation, licensure, specialty certification and revalidationin medicine.

Boulet J1, van Zanten M.

Author information

• 1Foundation for Advancement of International Medical Education and Research (FAIMER), Philadelphia, Pennsylvania, USA.

Abstract

CONTEXT:

The accreditation of medical school programmes and the licensing and revalidation (or recertification) of doctors are thought to be important for ensuring the quality of health care. Whereas regulation of the medical profession is mandated in most jurisdictions around the world, the processes by which doctors become licensed, and maintain their licences, are quite varied. With respect to educational programmes, there has been a recent push to expand accreditation activities. Here too, the quality standards on which medical schools are judged can vary from one region to another.

OBJECTIVES:

Given the perceived importance placed by the public and other stakeholders on oversight in medicine, both at the medical school and individual practitioner levels, it is important to document and discuss the regulatory practices employed throughout the world.

METHODS:

This paper describes current issues in regulation, provides a brief summary of research in the field, and discusses the need for further investigations to better quantify relationships among regulatory activities and improved patient outcomes.

DISCUSSION:

Although there is some evidence to support the value of medical school accreditation, the direct impact of this quality assurance initiative on patient care is not yet known. For both licensure and revalidation, some investigations have linked specific processes to quality indicators; however, additional evaluations should be conducted across the medical education and practice continuum to better elucidate the relationships among regulatory activities and patient outcomes. More importantly, the value of accreditation, licensure and revalidationprogrammes around the world, including the effectiveness of specific protocols employed in these diverse systems, needs to be better quantified and disseminated.

© 2013 John Wiley & Sons Ltd.

PMID:

 

24330120

 

DOI:

 

10.1111/medu.12286

[PubMed - indexed for MEDLINE]