말레이시아 의사면허시험: 이것이 나아갈 길인가?(Education in Medicine Journal. 2017)

말레이시아 의사면허시험: 이것이 나아갈 길인가?(Education in Medicine Journal. 2017)
Malaysian Medical License Examination (MMLE): Is This a Way Froward?
Amit Bhardwaj1, Kavitha Nagandla2, Sadoon Ibrahim3

 

 

소개
INTRODUCTION

말레이시아의 의학교육은 현재 이 시스템이 근본적인 환자 중심 치료를 위한 적절한 역량을 갖춘 의사를 배출하는지에 대한 도전에 직면해 있습니다(1). 현재 기존 교육 프로그램이 안전하고 유능한 의사를 배출하는 커리큘럼을 제공하는 데 충분히 견고한지 평가하는 프로세스가 없습니다. 보건부(MOH)는 모든 졸업생이 의사 면허를 취득하기 전에 반드시 응시해야 하는 공통 면허 시험으로 말레이시아 의사 면허 시험(MMLE)을 제안했습니다. 현재 이 시험은 외국 의과대학을 졸업한 말레이시아 학생들만 응시할 수 있습니다. 말레이시아 현지의 모든 공립 및 사립 대학은 학부생들이 향후 하우스맨십을 준비할 수 있도록 서로 다른 커리큘럼을 가지고 있습니다. 이 문제를 고려할 때 말레이시아의 모든 졸업생에게 의무적으로 의료 면허 시험을 실시하면 지식과 기술을 모니터링하는 데 도움이 될 수 있습니다. 말레이시아도 현지 대학 졸업생을 포함한 모든 의대 졸업생에게 의무 면허 시험을 고려할 때가 되었을까요? 
Medical education in Malaysia is currently facing challenges in trying to address whether the system produces doctors with adequate competencies for fundamental patient-centred care (1). Currently there is no process to evaluate whether the existing educational programs are robust enough in delivering curricula that produce safe and competent doctors. The Ministry of Health (MOH) proposed the Malaysian Medical Licensing Examination (MMLE) as a common licensing examination for which all graduates must sit prior to obtaining registration to practice. Currently, this exam is only taken by Malaysian students graduating from foreign medical colleges. All the local Malaysian universities, both public and private, have different curricula for preparing undergraduates for future housemanships. Considering this issue, a mandated medical licensing exam for all graduates in Malaysia could help in monitoring their knowledge and skills. Is it time for Malaysia to consider a mandatory licensing exam for all medical graduates, including those of local colleges?

말레이시아 의료 면허 시험의 동인
THE DRIVERS FOR MALAYSIAN MEDICAL LICENSING EXAM

역사적 맥락
Historical Context

미국과 캐나다의 데이터는 졸업 시험이 유효하고 신뢰할 수 있으며, 졸업생의 임상 능력과 향후 성과 사이에 적절한 상관관계가 있음을 보여줍니다(2). 면허 시험에서 더 나은 성적을 거둔 학생이 더 나은 환자 진료를 수행한다는 증거도 있습니다(3, 4). 그러나 평판이 좋은 대학의 연구 결과에서 국가 면허 시험과 환자 치료 결과 개선 사이의 직접적인 연관성을 입증하지 못했다는 점은 우려스러운 부분입니다(5, 6).
Data from the US and Canada demonstrate that exit exams can be valid and reliable, showing adequate correlation between a graduate’s clinical skills and future performance (2). There is evidence suggesting that students who perform better in licensing exams practice better patient care (3, 4). However, it is concerning that findings from reputable universities have failed to establish a direct link between national licensing examinations and improved patient outcomes (5, 6).

정치적 맥락
Political Context

말레이시아의 세계화로 인해 의사에 대한 수요가 증가했으며, 이러한 수요는 사립 의과대학에서 충족되었습니다. 이러한 의과대학에 대한 인증은 국가 인증위원회와 말레이시아 의학위원회에서 수행합니다. 인증 시스템이 있음에도 불구하고 측정은 주로 결과보다는 과정에 초점을 맞추고 있습니다(7, 8). 따라서 기대되는 역량을 표준화하는 역할을 할 수 있는 국가 의료 면허 시험이 필요합니다. 이는 아마도 환자 안전이 주도하는 사회 문화적 변화로 인식될 수 있습니다.

• 반면, 의과대학의 허점을 드러내는 시험이 의과대학의 권한에 어떤 영향을 미칠 것이며, 자율성을 유지하려는 의과대학의 기득권과 충돌하지는 않을까요?
• 또한, 면허 시험이 모든 동남아시아국가연합(ASEAN) 국가에서 유효한 것으로 간주될까요? 국경을 넘어 의료 서비스를 제공하는 의료 전문가의 업무가 중요한 것으로 간주되는 아세안 경제 공동체(AEC) 이니셔티브를 지원할 수 있을까요(9)?

Globalisation in Malaysia has resulted in an increased demand for doctors, and this demand has been fulfilled by private medical schools. The accreditation of these medical schools is conducted by the National Accreditation Board and the Malaysian Medical Council. Despite an accreditation system, measurements have largely focused on processes rather than outcomes (7, 8). Therefore, the compulsion is for a national medical licensing examination that can serve to standardise the competencies expected. This would perhaps be perceived as a socio-cultural change driven by patient safety.

• On the other hand, how will an exam that exposes the lacunae in medical schools affect the power of the colleges and will it conflict with their vested interest in retaining autonomy over their businesses?
• Furthermore, will the licensing examination be considered valid in all the Association of Southeast Asian Nations (ASEAN) countries and will it support the ASEAN economic community (AEC) initiative, for which the practice of health professionals providing cross-border health services is considered crucial (9)?

세계의학위원회(GMC)는 기본 의학 학위를 어디서 공부했는지에 관계없이 모든 졸업생에게 의료 면허 평가(MLA)를 의무적으로 이수해야 한다고 발표했습니다. 2020년까지 GMC 등록을 위한 공통 기준을 설정하는 것이 목표입니다. 이러한 선례와 말레이시아 의료 정책 지침에 영국 프로토콜을 채택한 것을 통해 저자는 말레이시아 의료 위원회가 말레이시아의 미래 의료 교육을 선도하고 있다고 말합니다(10).
The General Medical Council (GMC) has announced that completion of the Medical Licensing Assessment (MLA) is mandatory for all graduates, irrespective of where they studied for their basic medical degree. The aim is to set a common threshold for entry into the GMC register by 2020. With this precedent, and with the adoption of UK protocols into Malaysian health care policy guidelines, the authors opine that the Malaysian Medical Council is leading medical education in Malaysia into the future (10).

교육적 맥락
Educational Context

말레이시아의 대부분의 의과대학은 커리큘럼 전달을 위해 장기 시스템 기반 모듈을 사용하는 통합 접근 방식을 채택하고 있습니다. Richard Hays는 잠재적, 계획된, 전달된, 평가된 커리큘럼과 숨겨진 커리큘럼 간의 차이점과 관계를 설명했습니다(11). 계획된 교육과정, 전달된 교육과정, 평가된 교육과정이 일치하지 않으면 계획된 교육 목표 달성에 방해가 되는 바람직하지 않은 교육과정(숨겨진 교육과정)이 드러날 수 있으며, 이를 교육과정 전쟁이라고 합니다(그림 1). 국가 면허 시험은 평가되는 커리큘럼을 명시함으로써 의과대학이 계획대로 커리큘럼을 제공하고 있는지 판단하는 데 도움이 될 것으로 기대됩니다. 그러나 면허 시험이 부과되면 새롭고 혁신적인 교수 학습 전략을 교육과정에 도입하려는 열정이 꺾일까요? (12). 또한, 면허 시험이 시행되면 MMLE를 통합하고 평가 간 중복을 피하는 통일된 자격 최종 시험을 개발하기 위해 말레이시아 의학위원회 및 의과대학 평가 전문가를 포함한 주요 이해 관계자의 조정된 계획이 필요합니다.
The majority of medical schools in Malaysia have adopted an integrated approach that uses organ systems-based modules for delivery of the curricula. Richard Hays has illustrated the differences and the relationship between potential, planned, delivered, assessed and hidden curricula (11). The planned, delivered and assessed curricula must match, as a mismatch might surface an undesirable curriculum—the hidden curriculum—that would hinder the achievement of the planned educational objectives, a concept referred to as a curriculum war (Figure 1). It is expected that a national licensing exam will make explicit the assessed curriculum; this will help to determine whether medical schools are delivering the curriculum as planned. However, if a licensing exam is imposed, would it deter enthusiasm for bringing new and innovative teaching and learning strategies into the curriculum? (12). Moreover, a licensing exam would mandate the need for coordinated planning by key stakeholders, including the Malaysian Medical Council and medical school assessment experts, in order to develop a unified, qualifying final exam that integrates the MMLE and avoids redundancy between assessments.

이론적 배경
Theoretical Context

국가 면허 시험의 근간이 되는 이론은 국가 시험을 통해 의사가 진료를 시작하기 전에 최소한의 역량 기준을 달성했는지 확인한다는 것입니다. 응시자가 국가 표준에 따라 유능하게 해결해야 하는 실제 임상 업무와 문제를 반영하는 임상 관련 청사진을 구축하는 것이 우선입니다. 스완슨 외(13) 및 반 데르 블뢰텐 외(14)에 따르면, 적절한 수준의 콘텐츠 유효성과 신뢰성을 달성하려면 임상 문제 전반에 걸쳐 광범위한 샘플링이 필요하다고 합니다. 효율적인 샘플링을 위해 객관식 구조화 임상시험(OSCE)과 객관식 문제를 결합하는 것이 해결책이 될 수 있습니다. 

• 그러나 어떤 평가 형식을 사용하든 모든 의과대학 졸업생의 실력이 우수하고 환자 안전이 보장되는지 얼마나 정확하게 판단할 수 있을까요? 
• 또한, 소송에 관한 문헌이 지식보다는 '소프트 스킬'에 더 초점을 맞추고 있다는 점을 고려할 때, 주로 지식 기반 또는 OSCE 스타일의 면허 시험이 이러한 역량을 적절하게 다룰 수 있을까요(14)? 

The theory underpinning the national licensing exam is that national examinations ensure that doctors have achieved minimum standards of competency before beginning to practice. The priority is the construction of a clinically relevant blueprint that reflects the actual clinical tasks and problems that the candidates will be required to competently address in accordance with national standards. According to Swanson et al. (13) and Van der Vleuten et al. (14), a wide sampling across clinical issues is required if an adequate level of content validity and reliability is to be achieved. The solution is perhaps to combine the objective structured clinical examination (OSCE) with multiple-choice questions for efficient sampling.

• However, whatever assessment format is used, how precisely will one be able to determine whether every graduate of every medical school is good and that patient safety is assured?
• Furthermore, given that the literature on litigation focuses more on ‘soft skills’ than on knowledge, will a licensing exam that is largely knowledge-based, or even OSCE-style, address this competency adequately (14)?

미국 의사 면허 시험(USMLE) 1단계 및 2단계 점수를 대학원 레지던트 선발 결정에 계속 사용하는 것에 대한 실망스러운 보고도 있습니다(4). 산부인과 핵심 역량 절차에 대한 말레이시아 전공의 수련(n = 407)에 대한 최근 전국적 연구에서, 의과대학 졸업생들마다 어느 의대를 졸업했느냐에 따라 전공의 수련에 시작할 때의 절차적 기술과 지식 적용에 눈에 띄게 차이가 있다는 우려가 확인되었습니다. 이 연구는 하우스맨십을 준비하는 대학원 교육의 적절성과 관련하여 의과대학에 제공하는 피드백에 시사점을 제공합니다. 이 연구 결과는 MMLE에 의한 통합 평가 또는 의과대학의 최종 시험에 MMLE를 통합해야 할 필요성을 강조합니다(15,16).
There are discouraging reports on the continued use of United States Medical Licensing Examination (USMLE) Step 1 and Step 2 scores for postgraduate medical residency selection decisions (4). In a recent nationwide study on the Malaysian house officers training (n = 407) needs in core competency procedures in Obstetrics & Gynaecology, concerns were identified that graduates from different medical schools exhibited noticeably variable procedural skills and knowledge application upon entering their housemanships. This study has implications for the feedback given to medical schools regarding the adequacy of graduate training in preparation for housemanships. This finding highlights the need for a unifying assessment by MMLE or for the integration of MMLE into medical schools’ final exams (15,16).

사회경제적 맥락
Socioeconomic Context

시험의 이점이 시험 비용을 정당화하기에 충분한가? 시험의 이점에 대한 증거는 명확하지 않습니다(6). 국가가 이러한 시험의 결과를 측정하고 관리할 준비가 되어 있는가? 이 시험은 최근 졸업생들의 재정적 부담을 더욱 가중시킬 것입니다. 좋은 문제를 출제하는 방법과 표준 시험에 대한 여러 의과대학의 동의를 얻는 방법 등이 또 다른 과제입니다. 문제를 계획하고, 구성하고, 시험 결과를 분석하는 과정은 고된 작업입니다. 시험을 치를 수 있는 공간, 시험에 필요한 자금, 그리고 이 과정을 시작하고 유지할 수 있는 헌신적인 교수진이 상당히 필요합니다.
Are the advantages of the examination sufficient to justify its expense? Evidence of the exam’s benefits is far from clear-cut (6). Is the country ready to measure and manage the outcomes of such an exam? The exam will further increase the financial burden on recent graduates. Other challenges include how to write good questions and how to obtain agreement among different medical schools on the standard exam. The process of planning, constructing the questions and analysing the exam’s results is arduous. There is a significant need for space to accommodate the test, money to fund it, and committed faculty to initiate and maintain the process.

결론
CONCLUSIONS

사립 의과대학의 수를 늘림으로써 인력 수요 증가를 충족시킬 수 있다는 것은 의심의 여지가 없습니다. 그러나 자격을 갖춘 의사가 원하는 결과를 달성 할 수 있도록 의료 역량 표준화와 관련하여 계획, 자원 통합, 인프라 구축 및 품질 보증 시스템 개발에 대한 요구 사항이 있어야합니다. 이러한 요구가 해결된다면 의료 면허 시험은 의료 시스템을 발전시키고 말레이시아를 동남아시아 의학교육의 중심지로 만들 수 있는 길입니다. MMLE를 독립형 시험으로 유지하든, GMC의 계획대로 최종 시험에 통합하든, 이해관계자들은 면허 시험 시행을 위한 최선의 전략을 파악하기 위해 분석에 착수해야 합니다.
There is no doubt that an increase in work force demand is fulfilled by increasing the number of private medical schools. However, there should be requirements for the planning, consolidation of resources, infrastructure creation and development of a quality assurance system with regards to the standardisation of medical competencies so that qualified doctors are ensured to have achieved the desired outcomes. If this need is addressed, the way forward is a medical licensing exam that will advance the health care system and that can perhaps make Malaysia a nodal centre for medical education in South East Asia. Whether MMLE remains a standalone exam or is integrated into final exams, as planned by GMC mandates, stakeholders should undertake analysis to identify the best possible strategy for the implementation of the licensing exam.

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Medical education in Malaysia is facing challenges related to the increasing number of local private and foreign medical universities. The key issue is whether the system is producing doctors who have adequate competencies for fundamental patient-centred care. The Malaysian Medical Licensing Examination (MMLE) was proposed by the Ministry of Health (MOH) as a common licensing examination for which all graduates must sit prior to obtaining registration to practice. Currently, this exam is only taken by Malaysian students graduating from foreign medical colleges. However, the local Malaysian universities, both public and private, have different curricula for preparing undergraduates for future housemanships. The question is whether the educational programs of these universities are robust enough in delivering curricula that produce safe and competent doctors. Moving forward, it must be determined whether there is a need for extending the Malaysian Medical Licensing Examination (MMLE) to all graduates of both local and foreign medical universities, thereby creating a marker of excellence by which to measure Malaysian education and practice.