● Summary of Educating Physicians: A Call for Reform of Medical School and Residency

Summary of Educating Physicians: A Call for Reform of Medical School and Residency

Abstract:

This summary is based on the Jossey-Bass publication of the same title, Educating Physicians: A Call for Reform of Medical School and Residency (June 2010).

THE STUDY

본 연구는 '전문직이 되기 위한 준비'에 대하여 The Carnegie Foundation for the Advancement of Teaching에서 수행한 더 큰 프로그램의 한 부분이다. 본 연구는 Atlantic Philanthropies 의 지원을 받아 이루어졌으며, 결과물인 Educating Physicians: A Call for Reform of Medical School and Residency는 성직자, 법관, 엔지니어, 간호사 교육에 대한 보고서의 자매편이라 할 수 있다.

This study was part of a larger program of research by The Carnegie Foundation for the Advancement of Teaching on preparation for the professions. The work was funded by a grant from the Atlantic Philanthropies and the resulting book, Educating Physicians: A Call for Reform of Medical School and Residency, is a companion to reports on educating the clergy, lawyers, engineers, and nurses.

1909년 아브라함 플렉스너는 미국과 캐나다의 모든 155개의 의과대학을 방문하였고, 1910년 Medical Education in the United States and Canada라는 보고서를 저술하였다. 플렉스너는 현장 방문을 연구 프로토콜의 하나로서 도입한 선구자이며, 카네기 재단의 연구자들은 플렉스너로부터 많은 힌트를 얻었다.

Beginning in 1909, Abraham Flexner went to all 155 of the medical schools in the United States and Canada. In 1910 he released Medical Education in the United States and Canada. Flexner pioneered the idea of site visits as a research protocol, and Carnegie’s researchers took many of their cues from Flexner.

연구 프로토콜을 디자인하고 연구에 대한 허가를 받은 후 본 연구의 연구진은 AAMC의 LCME로부터 인증을 받은 미국 내 130개 의과대학을 방문하였다. 연구진은 열한 개 의과대학과 연계된 Academic medical center의 내과와 외과 레지던트 프로그램도 방문하였으며, 세 개의 non-university teaching hostpital도 방문하였다.

After designing the study protocol and receiving approval from human subject review boards of the Carnegie Foundation and the University of California, San Francisco, the research team visited eleven of the 130 medical schools in the United States currently accredited by the Liaison Committee for Medical Education of the Association of American Medical Colleges. The team also visited residency programs in internal medicine and surgery at the academic medical centers affiliated with those eleven medical schools as well as at three non-university teaching hospitals.

이 기관들은 미국 내에 위치한 연구중심 의과대학, 지역사회중심 의과대학, academic medical center, non-university teaching hospital을 모두 포괄하고 있다.

The institutions thus represent the array of research intensive and community-based medical schools, academic medical centers, and non-university teaching hospitals where U.S. medical education is located.

방문한 기관은 다음과 같다.

The sites were:

• • Atlantic Health, Morristown, New Jersey

• • The Cambridge Hospital, Cambridge, Massachusetts

• • Henry Ford Hospital and Medical Center, Detroit, Michigan

• • Mayo Medical School, Rochester, Minnesota

• • Northwestern University, Chicago, Illinois

• • Southern Illinois University, Springfield, Illinois

• • University of California, San Francisco, San Francisco, California

• • University of Florida, Gainesville, Florida

• • University of Minnesota–Duluth, Duluth, Minnesota

• • University of North Dakota, Grand Forks, North Dakota

• • University of Pennsylvania, Philadelphia, Pennsylvania

• • University of South Florida, Tampa, Florida

• • University of Texas Medical Branch, Galveston, Texas

• • University of Washington, Seattle, Washington

SUMMARY

현재 북미 의학교육의 청사진은 1910년 아브라함 플렉스너의 보고서(Medical Education in the United States and Canada)에 기술된 것을 따르고 있다. 

The current blueprint for medical education in North America was articulated in 1910 by Abraham Flexner in his report, Medical Education in the United States and Canada, a comprehensive survey of medical education prepared on behalf of The Carnegie Foundation for the Advancement of Teaching and at the request of the American Medical Association’s Council on Medical Education.

이제 의학교육은 다시 한 번 갈림길에 섰다.

Now medical education in the United States is at a crossroads:

플렉스너는 의학과 의학교육에 있어서 과거의 전통이나 관습이 아닌 과학적 탐구와 발견이 미래를 가리키는 것이어야 하며, 오늘날에 들어서 이러한 경고는 더욱 의미가 있다.

Flexner asserted that scientific inquiry and discovery, not past traditions and practices, should point the way to the future in both medicine and medical education. Today, this admonition seems even more compelling,

의학 내적인 환경의 힘과 그 변화에 대응하기 위해서 사실상 의료전문직 내 모든 기관은 의학교육에 대해서 다시 살펴볼 필요가 있다.

Responding to these environmental forces and changes within medicine, virtually every organization within the medical profession is re-examining medical education.

그리고 이들은 모두 근본적인 질문을 던지고 있다. "어떻게 의학교육을 향상시킬 수 있을 것인가?", "더 유능하고 더 공감할 수 있는 의사를 더 효과적, 효율적으로 키워낼 수 있는가?

all asking fundamental questions, such as: How can we improve medical education? Can we produce competent and compassionate physicians more efficiently and effectively?

연구진은 현재 의학교육의 상태를 점검하고 미래를 위한 방향을 제시하고자 하였다. 플렉스너의 발자취를 따라가며 전국의 의과대학과 대학병원을 방문하였다. 

The research team set out to examine the status of medical education and to chart the course for the future. Following in Flexner’s large footsteps, they visited medical schools and academic health centers around the country.

그러나 플렉스너 시대처럼 교육의 질에 있어서 의과대학 사이의 큰 격차가 있지는 않았다.

Unlike Flexner, however, they did not find great disparities in the quality of education among the medical schools visited.

1910년 이후로 발달하기 시작한 두 개의 중요한 외부 기관 - 인증시스템과 면허시스템 - 이 의학교육의 기본을 확고히 하고 있었다.

they recognized that two important external agents, the accrediting and licensing systems—which have become well-developed since 1910—ensure a baseline of quality in medical education

1909년 플렉스너가 비판한 이후 의학교육이 발전하고 있는 것은 맞으나, 플랙스너는 아마 의학교육의 낡은 구조와 형태가 지속적으로 의학교육을 둘러썬 내부/외부의 변화를 극복할 수 있을 것인지 의문을 가질 것이다.

Medical education has certainly evolved since Flexner’s critique in 1909. However, he might wonder if the old structures and forms of medical education can continue to meet the rising challenges, both internal and external, to medical education.

의학교육의 근본적 변화를 위해서는 새로운 교육과정, 새로운 교육법, 새로운 평가법이 필요하다.

Fundamental change in medical education will require new curricula, new pedagogies and new forms of assessment.

다행스럽게도, 이러한 비전은 이미 그 형태를 보여주고 있다.

Fortunately, this vision is beginning to take shape.

Time to Heal을 통해 Kenneth Ludmerer 가 지적한바와 같이 플렉스너가 옹호했던 방식의 개혁은 이미 그가 보고서를 내기 이전부터 시작중이었다. 마찬가지로 연구진은 많은 창의성과 혁신이 진행중임을 확인할 수 있었다.

As Kenneth Ludmerer points out in Time to Heal, the reforms that Flexner advocated were underway well before he issued his critique. Similarly, the researchers observed much creativity and innovation in the course of their field work and study of the literature on medical education and the learning sciences.

그러나 플렉스너가 그 당시에 그랬던 것처럼, 연구진은 의학교육이 많은 부분에서 부족하다는 것도 확인하였다.

However, as did Flexner in his time, the Carnegie researchers found medical education lacking in many important regards. 

수련과정은 경직되어있었고, 길고, 학습자 중심이 아니었으며

Medical training is inflexible, excessively long and not learner centered. 

임상교육은 입원환자 중심으로, 임상교수들은 점점 교육에 쓸 시간을 잃어가고 있었고 관련한 대부분의 업무를 레지던트에게 미룬 상태였다. 병원도 이들의 교육 업무를 지원하기에는 한계에 다다랐다.

They found that clinical education is overly focused on inpatient clinical experience, supervised by clinical faculty who have less and less time to teach and who have ceded much of their teaching responsibilities to residents, and situated in hospitals with marginal capacity to support their teaching mission. 

형식적 지식과 실제적 학습간 연결이 약했고, 환자집단, 의료전달체계, 효율성에 대한 관심은 점차 줄어들고 있었다.

They observed poor connections between formal knowledge and experiential learning and inadequate attention to patient populations, systems of health care delivery, and effectiveness. 

학습자들은 환자와 '함께'일할 기회가 부족했고, 시간에 따라 질환이 진행되고 회복되는 동안 환자가 어떻게 변하는지 볼 시간이 없었다. 학생과 전공의는 '의사노릇'이외의 의사의 역할에 대한 이해가 부족했다.

Learners have inadequate opportunities to work with patients over time and to observe the course of illness and recovery; students and residents often poorly understand non-clinical physician roles. 

의학교육은 학습과학(learning science)를 활용하지 못하고 있었고, 마지막으로 보건의료의 속도와 상업적 속성이 전문직의 기본적 가치를 손상시키고 있었다.

The team observed that medical education does not adequately make use of the learning sciences. Finally, time and again the researchers saw that the pace and commercial nature of health care impede the inculcation of fundamental values of the profession.

현장 방문에 앞서서 연구진은 교수진, 학장, 교육부학장, CEO등을 면담하였다. 대부분의 현장방문은 3일간 진행되었다.

Prior to each site visit, the team interviewed approximately ten faculty members, the dean, the education-related associate deans, and the CEO of the teaching hospital. Most site visits lasted three days, included the authors plus other Carnegie staff, and involved further interviews.

전체 현장방문동안 연구진은 총 184회의 면담, 104회의 포커스그룹 인터뷰, 100회의 참관을 하였다.

Over the course of the site visits, the team conducted approximately 184 interviews, 104 focus groups and 100 observations.

의학교육 및 학습과학과 관련된 문헌을 살펴보았으며 현장방문 전, 현장방문 중, 현장방문 후에 걸쳐서 AAMC, AMA, SDRME등의 여러 집행부와 직원들과 상담했다.

The team also reviewed the literature on medical education and the learning sciences as a means of guiding the interpretations of results and recommendations. Before, during and after the site visits, they consulted widely with the leadership and staff of the Association of American Medical Colleges, the American Medical Association, the Society of Directors of Research in Medical Education, and other medical professional organizations;

TOWARD A VISION FOR THE FUTURE OF MEDICAL EDUCATION

연구의 핵심 결과에 근거하여, 연구진은 의학교육에 대해서 네 개의 목표를 제언하였다.

Based on the study’s key findings, the team recommends four goals for medical education: 

학습성과의 표준화외 학습과정의 개별화

standardization of learning outcomes and individualization of the learning process; 

1. In the Flexner model two years of basic science instruction is followed by two years of clinical experience. This model has been perpetuated through the system of accreditation. However, medical education should now instead standardize learning outcomes and general competencies and then provide options for individualizing the learning process for students and residents

지식과 임상경험의 통합

integration of formal knowledge and clinical experience; 

2. In practice physicians must constantly integrate all aspects of their knowledge, skills and values. Moreover, physicians educate, advocate, innovate, investigate and manage teams. Students and residents need to understand and prepare for the integration of these diverse roles, responsibilities, knowledge and skills; and their learning in the basic, clinical and social sciences should be integrated with their clinical experiences. To experience integration of skills and knowledge in a way that prepares them for practice, medical students should be provided with early clinical immersion, and residents should have more intense exposure to the sciences and best evidence underlying their practice.

탐구 및 혁신하는 태도 함양

development of habits of inquiry and innovation; 

3. A commitment to excellence involves developing the habits of mind and heart that continually advance medicine and health care; this applies to institutions as well as individuals. To help students and residents develop the habits of inquiry and improvement that promote excellence throughout a lifetime of practice, medical schools and teaching hospitals should support the engagement of all physicians-in-training in inquiry, discovery and systems innovation.

전문직의 정체성 형성에 집중

focus on professional identity formation:

4. Professional identity formation—the development of professional values, actions, and aspirations—should be the backbone of medical education, building on an essential foundation of clinical competence, communication and interpersonal skills, and ethical and legal understanding, and extending to aspirational goals in performance excellence, accountability, humanism and altruism.

ESSENTIAL EDUCATIONAL GOALS

현재 교육과정 내용과 관련해서, 필수과정과 그 외의 것들이 좀 더 확실히 구분되어야 한다. 의학지식과 기술이 지속적으로 진화한다는 것을 감안하면, 5년 혹은 10년 지난 것들은 최소화되어야 한다.

• • With respect to curricular content, educators must distinguish more clearly between core material and everything else. Given that the medical knowledge base and the skills required to practice effectively are constantly evolving, it is crucial that curricular material with a five- or tenyear date-stamp is minimized.

어떤 단계에서든, 학습자들이 해당 단계에 요구되는 적절한 수준의 역량을 갖췄다면 불필요하게 반복하느라 시간을 낭비할 필요가 없다. 의학교육은 교육과정을 더 유연하게 디자인함으로서 개별 학습자들이 다양한 난이도의 학습을 할 수 있게 해야한다.

• • Learners at all levels should not be obliged to spend time unproductively repeating clinical activities once they have mastered the competencies appropriate to their level. Medical education must make much more use of readiness assessments and design curricula that are sufficiently flexible to allow individual learners to engage at various levels of difficulty. Eliminating non-core activities will free up time for students and residents to develop additional depth in areas of individual interest and to explore the non-clinical roles of physicians.

모든 단계에 있어서, '역량은 최소기준'임을 강조해야 한다. 이는 필수내용(core)와 관련해서 의사가 되려고 하는 사람이면 누구든 갖춰야 하는 것이다. 학습자는 수월성을 갖추기 위해서 노력해야하며, 이를 위해서 의과대학과 전공의 프로그램은 학습자가 평생에 걸쳐 수월성을 추구할 수 있도록 격려해야 한다. 

• • At every level, the approaches to teaching must emphasize that "competence means minimal standard"; it is the level of performance that all aspiring physicians must attain with respect to the core. It is essential that the aspirational nature of the quest for excellence be communicated to and inculcated in learners. For this reason, medical schools and residency programs must encourage learners to form lifelong commitments to pursuing excellence, instilling in students and residents the understanding that learning continues beyond the formal four- to ten-year training period, and preparing them to continuously incorporate the advancing knowledge base and procedural innovations of contemporary medicine.

의학교육은 근본적으로 학습자들이 스스로 동기를 부여하고, 스스로 학습하며, 임상경험으로부터 자극을 받고, 스스로의 진료 효율성에 대한 정보에서 자극을 받아 다른 사람들과 상호작용하는 것이어야 한다. 이같은 '학습 나선'은 이미 가지고 있던 지식, 임상경험, 새로운 질문을 서로 연결시켜준다. 

• • The fundamental pedagogy of medical education aims to have learners develop the motivation and skill to teach themselves, stimulated by their clinical experiences, information about the effectiveness of their care, and interactions with others in the clinical environment. This “learning spiral” connecting prior knowledge, clinical experience, identification of next questions, and formal study should be presented to medical students and residents as the basis for the metacognitive monitoring of their own approaches to learning. To the greatest extent possible, learners should approach curricular material, including the sciences foundational to medicine, through questions arising out of clinical work; this is as important for residents as it is for early medical students.

의학교육의 전 과정에 걸쳐서 학생과 전공의는 교수들과의 관계를 통해 도전정신을 갖고, 롤모델을 찾고, 개별지도의 기회를 갖도록 해야 한다.

• • Throughout their medical education, students and residents require strong, engaged relationships with faculty members that provide challenge, support and strong role modeling, as well as the opportunity for individual guidance.

의과대학과 전공의 교육 둘 다에 있어서, 평가를 통해서 학습자들이 '필수 영역'의 정해진 역량수준에 도달할 수 있어야 한다. 의과대학부터 수련후까지 이어진 학습의 연속체(continuum)에 걸쳐서 평가는 공통된 역량 영역(competency domain)을 사용하고, 어떤 단계에서 어느 수준에 도달해야하는지 기준을 제시해야 한다.

• • At both the medical school and residency levels, medical education must ensure, through assessment, that learners achieve predetermined standards of competence with respect to knowledge and performance in core domains. Assessment should use a common set of competency domains over the entire learning continuum with actual benchmarks specified by learner level. There are successful examples of this kind of assessment over a developmental spectrum from which medical education should learn. Such benchmarking, shared nationally, would allow medical schools, residencies and learners to understand how programs compare in terms of the capabilities of their entering learners, and what the education that they provide adds as measured by the performance of their graduates.

평가는 단순히 학생과 레지던트가 현재 무엇을 알고 있고 무엇을 할 수 있느냐를 알려주는 것을 넘어서 무엇을 더 해야하고, 다음 단계는 무엇인지를 알려줄 수 있어야 한다. 그러한 'gap'에 대해서 아는 것이 평생학습을 이끌기 때문이다. 역량에 대한 평가는 통합적이어야 하고 누적되어야 한다.

• • Assessment must go beyond what students and residents know and can do to address learners’ ability to identify gaps and next steps for learning, as it is the appreciation of those gaps that should drive lifelong learning. To discourage learners’ segmentation of knowledge and skills, and to reinforce the development of well-networked understandings of medical phenomena, assessment across the competencies should be integrated and cumulative.

수월성을 추구하는 것은 의학의 전문직으로서 갖춰야 할 특징이다. 전문성(expertise)는 헌신에서 나오는 것이 저절로 얻어지는 것이 아니다. 

• • Commitment to excellence is a hallmark—some would maintain the hallmark—of professionalism in medicine; expertise is likewise a commitment, not an attribute. This concept is fundamental to the team’s view of medical education and knits together the goals of standardization and individualization, integration, innovation and improvement, and identity formation.

위 목표들은 각각 의사의 전문직으로서의 정체성 영역에 해당된다.

Each of the goals refers to a dimension of professional identity of physicians:

표준화를 통한 질의 확보

• • the assurance of quality accomplished through standardization;

학습자를 인간적으로 대하고, 각각의 차이, 능력, 경험을 존중하며 높은 성취를 유도하는 교육적 과정

• • an educational process of individualization that treats learners humanely, respects their different interests, abilities and experiences, and encourages high achievement;

수련을 마친 후 뿐만 아니라 수련기간에도 사회에서 다양한 역할을 할 수 있다는 기대

• • the expectation that physicians play a broad role in society, even during training; and

모든 의사들이 현장(field building)에 참여한다는 주장

• • the insistence that all physicians participate in field building.

프로그램은 학습자의 경험을 고려해야 하며, 교육과정/교육법/평가법에 의해서 노골적으로 또는 은유적으로 전해지는 메시지를 경계해야 한다. 그렇지 않으면 그 프로그램에 의한 전문직 양성의 결과는 왜곡될 것이다.

Programs must be deliberate about learners’ experiences and vigilant about the implicit and explicit messages conveyed by the curriculum, pedagogy and assessment; otherwise, the professional development outcomes desired by the program may be distorted or subverted.

SUPPORTING EXCELLENCE THROUGH EFFECTIVE POLICY

미국에서 의학이 전문직으로 살아남을 수 있었던 것은 의학교육의 다양한 이해관계자들이 지속적으로 교육과 진료에 높은 기준을 요구해왔기 때문이다.

Medicine as a profession has thrived in the United States in part because medical education’s considerable array of stakeholders has continued to insist on high standards for education and practice. 

따라서 교육과정 학장, 전공의 프로그램 관리자, 교과목/실습 관리자가 교육 프로그램을 설계하는데 직접적으로 관계되어 있지만 이들도 역시 외부 요인에 의해 제약을 받게 된다. 의과대학과 전공의프로그램을 효과적으로 개혁하기 위해서는 여기에 영향을 미칠 수 있는 자금을 제공하는 사람, 규제, 전문직 단체 등도 이 노력에 활발히 관려해야 한다.

Thus, although curriculum deans, residency program directors and course and clerkship directors have immediate responsibility for the design and delivery of educational programs, they work within constraints imposed by external entities. In order for medical schools and residency programs to successfully innovate, the funders, regulators and professional organizations that control and influence medical education must be actively engaged in this reform effort.

1. 1. The Association of American Medical Colleges (AAMC) and medical schools work together to revise pre-medical course requirements and admission processes, ensuring appropriate socio-economic and racial-ethnic diversity of those in medical training.

1. 2. Accrediting, certifying and licensing bodies together develop a coherent framework for the continuum of medical education and establish effective mechanisms to coordinate standards and resolve jurisdictional conflicts.

1. 3. CEOs of teaching hospitals and directors of residency programs align patient care and clinical education to improve both and develop educational programs that are consistent with practice requirements.

1. 4. Deans of medical schools and CEOs of teaching hospitals support the teaching mission of the faculty by providing financial support, mentoring, faculty development, recognition and academic advancement. 

1. 5. Deans of medical schools and CEOs of teaching hospitals collaboratively make funding for medical education transparent, fair and aligned with the missions of both medical schools and teaching hospitals. 

1. 6. AAMC, American Medical Association (AMA), Accreditation Council for Graduate Medical Education (ACGME), medical specialty societies and medical schools advocate for sustained private, federal, and state funding commitments to support infrastructure, innovation, and research in medical education. Medical education is a public good that should be supported by society.

1. 7. AAMC, AMA, ACGME, medical specialty societies and medical schools collaborate on the development of a medical workforce policy for the United States. A variety of interventions addressing the cost of medical education, length of training, and practice viability ensure that the country has the mix of specialty and subspecialty physicians to meet the needs of the population.

---

Summary of Educating Physicians: A Call for Reform of Medical School and Residency

Mon, 06/07/2010 - 8:26pm

Printer-friendly version

Molly Cooke, David M. Irby, Bridget C. O'Brien

Abstract: 

This summary is based on the Jossey-Bass publication of the same title, Educating Physicians: A Call for Reform of Medical School and Residency (June 2010).

(http://www.carnegiefoundation.org/elibrary/summary-educating-physicians)

Cooke, M., Irby, D. M., & O'Brien, B. C. (2010). Educating physicians: a call for reform of medical school and residency (Vol. 16). John Wiley & Sons.