의학교육의 글로벌 미션 포용하기(Acad Med, 2016)

의학교육의 글로벌 미션 포용하기(Acad Med, 2016)

Embracing Medical Education’s Global Mission

Paul E. Farmer, MD, PhD, and Joseph J. Rhatigan, MD

많은 저소득 및 중간 소득 국가의 보건 시스템은 훈련 된 의료 종사자의 부족으로 만성적으로 불구가된다. 1) 의사의 훈련을 위해 필요한 대규모 투자 및 긴 교육기간 때문에 의사의 부족은 해결하기가 특히 어렵다.

Health systems in many low- and middle-income countries are chronically crippled by shortages of trained health workers,1 and physician shortages are particularly difficult to address because of the large investments and long timelines needed to train physicians.

한 대륙은 특히 training의 어려움을 겪는다. "31 개국에는 의대가 없으며 그 중 9 개는 사하라 이남 아프리카에있다. 44 개국에는 의대가 하나 뿐이며, 그 중 17 개가 사하라 사막 이남 아프리카에있다. "[2] 당연히이 모든 국가들은 의사 및 기타 보건 전문가의 부족에 직면 해있다.

One continent is especially burdened by training shortfalls: “31 countries have no medical school whatsoever, nine of which are in sub- Saharan Africa; 44 countries have only one medical school, 17 of which are in sub-Saharan Africa.”2 Not surprisingly, all of these countries face shortages of physicians and other health professionals.

만성적으로 부족한 의료 시스템에 직면하는 저소득 및 중소 득 국가의 경우, 의료 교육에 자원을 할당하는 능력이 심각하게 제한됩니다. 매년 미국은 1 인당 보건에 약 9,000 달러를 지출하지만 사하라 사막 이남의 아프리카와 동남아시아의 여러 국가는 1 인당 1 인당 100 달러 미만을 지출한다.3

For low- and middle-income countries that face chronically underresourced health systems, the ability to allocate resources to medical education is severely constrained. each year the United States currently spends around $9,000 on health per capita while many nations in sub-Saharan Africa and several w.in southeast Asia spend less than $100 per capita.3 

중저 소득 국가에서 강화되어야 할 보건 시스템의 중요한 "구성 요소"가 많이 있지만 미국의 학술 의학이 인적 자원 : 의사, 간호사, allied health professional 등 독특한 기여를 할 수있는 분야에 집중하고자합니다 

While there are many important “building blocks” of health systems that need to be bolstered in low- and middle- income countries, we wish to focus on one where U.S. academic medicine can make unique contributions—namely, human resources: the physicians, nurses, and allied health professionals

저소득 및 중간 소득 국가에서 의학 교육을 강화하는 것은 의료진의 양적 질과 질을 향상시켜 이들 의료 시스템을 관리하고 이끌어내는 데 중요합니다.

Strengthening medical education in low- and middle-income countries is critical to improving the quantity and quality of physicians to staff and lead these health systems.

미국의 의료계는 수요 증가와 자원 감소로 종종 압박감을 느끼지만, 사실 세계의 대다수와 비교하여 풍부하게 수영하고 있습니다.

Although the U.S. academic medical community often feels squeezed by increasing demands and decreasing resources, we are swimming in abundance compared with the vast majority of the world:

또한 우리는 국경의 경계를 넘어 교육의 전문성에 대한 요구가 가장 큰 학교를 바라보아야 한다. 기술과 사회의 변화가 우리 직업을 급속히 변화시키고있는 세계에서 미국 의과 대학이 관련성이 있다면, 우리는 글로벌 시민으로서의 역할을 포용하고, 전 세계적으로 의학 교육의 발전을 우리의 전체 임무의 핵심 교리로 삼아야합니다. 세상이 점점 작아지면서 우리는 더 이상 출생이나 사고로 학교에 지원할 수있는 사람들만을 훈련하는 것으로 우리의 사명을 제한 할 수 없습니다.

We must also look beyond the walls of our schools and our borders to where the need for our expertise in education is the greatest. If U.S. medical schools are to remain relevant in a world where technological and social changes are rapidly transforming our profession, we need to embrace our roles as global citizens and make the advancement of medical education worldwide a core tenet of our overall missions. As our world grows smaller, we can no longer limit our mission as training only those who by an accident of birth or circumstance are able to apply to our schools.

U.S. Academic Medicine’s Global Engagements

다음은 몇 가지 혁신적 모델이다.

The following brief overview serves to highlight some innovative models.

학부교육에서의 혁신모델

• In undergraduate medical education, the partnership between the consortium of U.S. medical schools led by the University of Indiana Medical School and Kenya’s Moi University School of Medicine has not only seen a robust bidirectional exchange of faculty, medical students, and residents between the United States and Kenya, it has also resulted in the creation of an important health care delivery organization, the Academic Partnership Providing Access to Healthcare (AMPATH). While this organization began as an AIDS treatment program, AMPATH now also provides primary health care and additional health services in collaboration with the Government of Kenya to a population of 3.5 million people in western Kenya.4

• From 2010 to 2015, the Medical Education Partnership Initiative helped catalyze a network of African and U.S. medical school collaborations that was highly successful in strengthening medical education in Africa.5,6 Funded by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the National Institutes of Health, this initiative invested directly in African medical schools to improve the quality and quantity of graduates, retain physicians in the workforce, and increase research capacity. Despite its well-documented successes and uniform praise, the initiative’s funding is uncertain moving forward.

• The successes of Weill Cornell Medicine’s campus in Qatar7 and Duke University School of Medicine’s in Singapore8 provide another model of how U.S. medical schools can partner with institutions abroad to create high-quality medical education programs that provide an essential source of physicians for their respective countries.

졸업후교육에서의 혁신모델

• In postgraduate medical education, PEPFAR and the U.S. Agency for International Development (USAID) have supported the Rwanda Human Resources for Health Program, an innovative program that is a template for others currently proposed. This seven-year-long program, launched in 2012, focuses on the creation of new residency, nursing specialty, and health management programs in Rwanda. The program deploys approximately 100 U.S. medical faculty a year from a consortium of 23 U.S. academic medical centers and schools to Rwanda to serve as mentors to Rwandan faculty who are building new postgraduate residency programs.9 Over half the U.S. faculty spend more than six months a year in Rwanda, while the rest, often subspecialists, have shorter engagements. Faculty are given partial salary support and a stipend toward travel and living expenses through a grant from PEPFAR and USAID.

• Other notable efforts in postgraduate medical education are the Partnership for Health Advancement in Vietnam (HAIVN)10 and the Hôpital Universitaire de Mirebalais (HUM)11 in Haiti. 

• HAIVN is a collaboration between Harvard Medical School and two affiliated Harvard teaching hospitals, and the Vietnam Ministry of Health (MOH) and two prominent Vietnamese medical schools. This collaboration is supported by grants from the U.S. Centers for Disease Control and Prevention. HAIVN began as an effort to improve HIV care in Vietnam and has now made strengthening medical education through curriculum innovation and faculty development a priority focus. In addition to engagement with local medical schools, HAIVN works to support the Vietnam MOH to develop systems of accreditation and licensing in medical education. 

• In Haiti, HUM was built by a nongovernmental organization, Partners In Health (which both authors are affiliated with) and the Haitian MOH in response to the destruction of the national teaching hospital in the 2010 earthquake. HUM has engaged faculty members from Harvard Medical School to create a number of residency programs including internal medicine, general surgery, pediatrics, obstetrics–gynecology, and the only emergency medicine residency program in the country. All these programs are led by Haitian physicians, some of whom have returned to work in Haiti after careers in the United States and Europe.

의대생 공급을 늘리고 지역 내 의사를 보존하기

Increasing Medical Student Supply and Retaining Physicians

저소득 및 중산층 국가의 중등교육 개선을 위해 해결되어야 할 문제는 다양하지만, 의학교육 시스템의 개선이 단순히 부유층을 위한 것이 되지 않기 위해서는, 이 병목 현상을 반드시 인식하고 해결해야합니다. 

The challenges of improving secondary school education in low- and middle-income countries are manifold, but this bottleneck must be acknowledged and addressed if efforts to improve medical education systems will benefit more than those affluent enough to obtain a decent high school education.

국가 내에 의사와 교수진을 유지하기 위해서는, 의사들에게 그들이 배운 진료행위를 할 수 있도록 시스템을 갖추어 그 안에서 진료해볼 수 있는 기회가 필요합니다. 의학 교육을 향상시키기위한 노력은 더 많은 자격을 갖춘 의사를 양성하고, 의사를 가르치는 기회를 제공함으로써 시너지 효과를 발휘합니다. 이렇게 교육에 참여하게 만듦으로써 의사 만족도를 높이고 최신의 practice를 disseminate할 수 있는 가능성을 제공합니다.

To retain physicians and faculty in these nations, these physicians need opportunities to practice within systems that allow them to provide the care they are taught to deliver. Efforts to improve medical education have the synergistic effect of both training more and better-qualified physicians and providing opportunities for practicing physicians to engage in teaching. This engagement has the potential to increase physician satisfaction and to disseminate the most up-to-date practices.

또 다른 중요한 단계는, 우리가 다른 나라에서 수입하는 의사의 수를 줄일 수 있도록, 미국 내에서 충분한 의사를 우리 자신의 필요에 맞게 훈련시키는 것입니다. 미국으로 의사를 수출하는 많은 나라가 의사의 심각한 부족을 가지고 있습니다. 많은 국제 의료 졸업생 (IMG)의 의학 교육은 본국에서 많은 보조를 받고 있습니다.

Another important step is to ensure that we in the United States train enough doctors for our own needs to reduce the number of physicians we import from other countries, many of which have critical physician shortages. Many international medical graduates’ (IMGs’) medical educations are heavily subsidized by their home countries.

미국의 의대생 숫자와 1년차 전공의 숫자 사이의 큰 gap으로 인해서, 외국에서 미국으로의 의사 유입이 발생하는데, 이는 IMG들의 고국에서 투자된 경재적 투자와 인적 투자를 빨아들이는 것이다.  지난 10 년 동안 AAMC와 다른 사람들의 지도력 덕분에 새로운 학교가 개교하면서 다른 학교의 학급 규모가 확대되면서 미국 의대 졸업생이 늘어났습니다. 이로써 미국 의료 시스템의 1년차 레지던트 필요성과 미국 의과 대학 졸업생 공급의 격차가 줄긴 하겠지만, 이러한 격차는 여전히 존재하며 전문가의 예측에 기반을두고있을 것입니다.

Physician immigration to the United States, made possible by the large gap between the number of U.S. medical graduates and the number of first-year residency positions, drains both financial investments and human resources from IMGs’ home countries. Thanks to leadership by the AAMC and others over the past 10 years, there has been an expansion in graduates of U.S. medical schools as new schools have opened while others have increased their class sizes. Although this has closed the gap between the U.S. health system’s need for first-year residents and the supply of U.S. medical school graduates, this gap still exists and will likely remain based on expert projections.15

의학교육에 대한 접근성

Universal Access to Medical Education

미국 의과 대학은 이 글로벌 교육 임무를 포용함으로써 얻을 이익이 많다.

U.S. medical schools have a great deal to gain in embracing this global educational mission.

미국 의과 대학에서의 교육 혁신은 느리며 커리큘럼 개혁의 긴 사이클을 통해 이루어 지므로 이러한 작업에서 얻을 수있는 교훈은 제한적입니다. 해외의 새로운 의과 대학의 창설과 기존의 학교의 강화는 학습에 관한 가장 최근의 증거를 실천하고 이러한 방법을 반복적으로 완벽하게 완성 할 수있는 기회를 제공합니다. 우리가 글로벌 교육 커뮤니티로서 가장 효과적인 커리큘럼 도구를 가르치고 개발할 수있는 최상의 방법을 배우게되면,이를 글로벌 공공재로 광범위하게 공유 할 수 있습니다.

Educational innovation in U.S. medical schools is slow and takes place over long cycles of curriculum reform, limiting the lessons that can be drawn from such work. The creation of new medical schools abroad and strengthening of existing ones provide opportunities to put the most up-to-date evidence about learning into practice and to iteratively perfect these methods rapidly. Once we as a global educational community learn the best ways to teach and develop the most effective curriculum tools, these can be shared broadly as global public goods.

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Acad Med. 2016 Dec;91(12):1592-1594. doi: 10.1097/ACM.0000000000001433.

Embracing Medical Education's Global Mission.

Farmer PE1, Rhatigan JJ.

Author information

1

P.E. Farmer is Kolokotrones University Professor of Global Health and Social Medicine, Harvard University, chair, Department of GlobalHealth and Social Medicine, Harvard Medical School, and chief, Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts. J.J. Rhatigan is associate professor, Harvard Medical School, and associate chief, Division of Global Health Equity, Brigham and Women's Hospital, Boston, Massachusetts.

Abstract

Shortages of trained health care workers plague low- and middle-income countries around the world. When resources are scarce, the ability to support medical education is severely constrained. While there are many important "building blocks" of health systems that need to be bolstered in low- and middle-income countries, the authors propose that U.S. academic medicine can make unique contributions in the realm of human resource development-specifically, increasing the supply of physicians who directly provide health care to the populations they serve and who often manage and lead these health systems. Strengthening medical education in low- and middle-income countries is critical to improving the quantity and quality of physicians to staff and lead these health systems. The authors provide specific examples of how U.S. institutions are pursuing this global endeavor, including the Academic Partnership Providing Access to Healthcare in Kenya, the MedicalEducation Partnership Initiative throughout Africa, partnerships between U.S. medical schools and with institutions in Qatar and Singapore, and postgraduate medical education efforts in Vietnam and Haiti. They urge that the U.S. academic medicine community embrace this challenge as part of its mission to ensure that all those who, wherever they may live, have the ability, the dedication, and the compassion to pursue a career in medicine be given the opportunity to do so.

PMID:

 

27749305

 

DOI:

 

10.1097/ACM.0000000000001433