농어촌지역 의료인력 수급을 증가시키기 위한 의과대학 프로그램
Medical School Programs to Increase the Rural Physician Supply: A Systematic Review and Projected Impact of Widespread Replication
Howard K. Rabinowitz, MD, James J. Diamond, PhD, Fred W. Markham, MD, and Jeremy R. Wortman
목적 : 농어촌지역 의료인력 공급을 늘리기 위한 다양한 의과대학 프로그램의 결과를 총체적으로 분석하여, 더 많은 의과대학에 복제되어 도입되었을 때(widespread replication)의 영향을 추정해보고자 하였다.
Purpose : To systematically review the outcomes of comprehensive medical school programs designed to increase the rural physician supply, and to develop a model to estimate the impact of their widespread replication.
방법 : 가능한 가장 예전 문헌부터 2006년 10월까지 프로그램. (1)일차 목표가 농어촌지역 의료인력 공급 향상일 것 (2)학생 코호트가 정의되어 있을 것 (3)농어촌지역 입학전형 또는 농어촌지역 교육과정 확대에 초점을 둔 것.
Method : Relevant databases were searched, from the earliest available date to October 2006, to identify comprehensive programs (with available rural outcomes), that is, those that had (1) a primary goal of increasing the rural physician supply, (2) a defined cohort of students, and (3) either a focused rural admissions process or an extended rural clinical curriculum. Descriptive methodology, definitions, and outcomes were extracted. A model of the impact of replicating this type of program at 125 allopathic medical schools was then developed.
결과 : 10개의 연구가 inclusion criteria를 만족했다. 여섯 개 프로그램에서 30년에 걸쳐 배출한 1600명의 졸업생에 대한 결과를 얻을 수 있었다. "rural"의 정의에 따라 농어촌지역에서 진료를 하는 졸업생 비율은 53%~64%정도였다. 125개의 의과대학이 비슷한 프로그램을 매 년 10명의 학생에 대해 시행한다면, 다음 10년간 11390명의 농어촌지역 의료인력이 만들어지고, 이는 현재 추정치의 두 배를 넘어서는 숫자이다.
Results : Ten studies met all inclusion criteria. Outcomes were available for more than 1,600 graduates across three decades from six programs. The weighted average of graduates practicing in rural areas ranged from 53% to 64%, depending on the definition of rural. If 125 medical schools developed similar programs for 10 students per class, this would result in approximately 11,390 rural physicians during the next decade, more than double the current estimation of rural doctors produced during that time frame (5,130).
결론 : 의과대학 농어촌지역 프로그램은 농어촌지역 의사 공급을 몇 배로 증가시켰으며, 이 모델을 복제하여 널리 퍼뜨리는 것은 수천개의 농어촌지역의 보건의료 접근성에 영향을 줄 수 있을 것이다.
Conclusions : All identified comprehensive medical school rural programs have produced a multifold increase in the rural physician supply, and widespread replication of these models could have a major impact on access to health care in thousands of rural communities. The current recommendation to expand U.S. medical school class size represents a unique and timely opportunity to replicate these programs.
농어촌지역 의료인력의 숫자가 감소하는 요인에는 가정의학과 일차의료에 들어오는 의사 수도 포함되며, 의학을 전공하는 여성이 늘어나고 있는 점, 젊은 의사들 사이에서 라이프스타일의 선호가 변화하는 점, 의과대학학생들이 가진 부채가 늘어나는 점 등이 있다.
Factors associated with this decline include the decreasing number of physicians entering family medicine and primary care,1,7 the increasing number of women in medicine,8 the changing lifestyle preferences of younger physicians,1 and the increasing level of medical student debt.9
Table 1에 나와있는 것처럼 이들 프로그램의 통해 26~92%의 의사들이 농어촌지역에서 종사하고 있으며, 이는 현재 농어촌지역으로 가고자 하는 비율(3%)이나 현재 농어촌지역에서 진료하고 있는 의사 비율(9%)보다 훨씬 높은 수치이다.
As seen in Table 1, the studies showed a range of 26% to 92% of physicians working in rural communities, which is multiple times greater than both the 3% rate of current students planning to go rural and the 9% of current physicians practicing rurally.
Table 2에서 나와있는 것처럼, Duluth의 결과와 PSAP의 결과에서 알 수 있는 것은, 모두 농어촌지역에서 진료하는 의사들이 그 지역에서 머무는 기간도 매우 길다는 것이다.
As seen in Table 2, retention outcomes from Duluth showed that 87% of graduates practicing family medicine in Minnesota communities of 30,000 or fewer people remained for a 1- to 20-year duration. PSAP outcomes showed that 79% of graduates practicing rural family medicine were continuing to do so 11 to 16 years after they were first located in practice (which occurred five to nine years after graduation).
10개의 연구는 방법론에서 차이가 있고 rural 의 정의를 서로 다르게 하고 있으나, 종합적으로 봤을 때 이들 프로그램의 효과는 농어촌지역에서 의사를 하려고 하는 졸업생의 비율 뿐만 아니라, 그 지역에서 진료를 지속하는 비율(rural retention rate)측면에서도 상당하다.
The 10 studies reviewed had wide variability in methodology, varying degrees of methodologic rigor, and used different definitions of rural. Nevertheless, taken in the aggregate, we believe that the evidence regarding the effects of these programs is substantial, with the rural outcomes from these individual programs—between 26% and 92%—all multiple times greater than both the 3% of recent students who have plans for rural or small-town practice and the 9% of physicians currently practicing in rural areas. Similarly, the rural retention rates of 79% to 87% are substantially higher than the national norm, where the median duration of rural primary care physicians practicing in the same area is seven years.28
일부 사람들은 입학 당시에 농어촌지역에서 진료할 학생을 어떻게 예측할 수 있느냐는 우려를 하지만, 여러 학교의 다년간의 경험은 이것이 가능하다는 충분한 근거가 된다.
Although some have raised concerns regarding the ability to predict at the time of admission to medical school which applicants will actually practice in rural areas, the fact that multiple schools have been doing this for decades provides strong evidence that it can be done.
또한 농어촌지역 프로그램에 들어오는 학생들의 질에 대한 우려도 흔한데, 이 역시 연구들을 통해서 이들이 동료와 비슷한 학업성취도를 보인다는 것이 확인되었다.
Also, despite common concerns regarding the quality of students in medical school rural programs, studies have shown their academic performance to be similar to that of their peers.16,20,36
Acad Med. 2008 Mar;83(3):235-43. doi: 10.1097/ACM.0b013e318163789b.
Medical school programs to increase the rural physician supply: a systematic review and projected impact ofwidespread replication.
Source
Department of Family and Community Medicine, Jefferson Medical College, Thomas Jefferson University, Suite 401, 1015 Walnut Street, Philadelphia, PA 19107, USA. Howard.Rabinowitz@jefferson.edu
Abstract
PURPOSE:
To systematically review the outcomes of comprehensive medical school programs designed to increase the rural physician supply, and to develop a model to estimate the impact of their widespread replication.
METHOD:
Relevant databases were searched, from the earliest available date to October 2006, to identify comprehensive programs (with availablerural outcomes), that is, those that had (1) a primary goal of increasing the rural physician supply, (2) a defined cohort of students, and (3) either a focused rural admissions process or an extended rural clinical curriculum. Descriptive methodology, definitions, and outcomes were extracted. A model of the impact of replicating this type of program at 125 allopathic medical schools was then developed.
RESULTS:
Ten studies met all inclusion criteria. Outcomes were available for more than 1,600 graduates across three decades from six programs. The weighted average of graduates practicing in rural areas ranged from 53% to 64%, depending on the definition of rural. If 125 medical schools developed similar programs for 10 students per class, this would result in approximately 11,390 rural physicians during the next decade, more than double the current estimation of rural doctors produced during that time frame (5,130).
CONCLUSIONS:
All identified comprehensive medical school rural programs have produced a multifold increase in the rural physician supply, andwidespread replication of these models could have a major impact on access to health care in thousands of rural communities. The current recommendation to expand U.S. medical school class size represents a unique and timely opportunity to replicate these programs.
