독일의 학부 의학교육

Undergraduate medical education in Germany

Jean-François Chenot1

1 Department of General Practice, University of Göttingen, Germany

Background

독일의 첫 의학 강의는 1388년 하이델버그에서 있었다. 가장 최근에 설립된 medical faculty 는 Witten-Herdecke 에 1992년 설립되었다. 독일의 의학교육은 한 때에는 미국 의학교육의 롤모델로 일컬어지기도 했다. 그러나 최근 독일의 의학교육은 미국, 캐나다, 영국이나 네덜란드와 같은 다른 유럽국가들이 어떻게 하는지를 살펴보고 있다.

In Germany, lectures in medicine were first given in 1388 in Heidelberg. The latest medical faculty was founded in Witten-Herdecke in 1992. Medical education in this country was once praised as a role model e.g. for American medical education by Abraham Flexner [1]. Nowadays, however, the German medical faculties are looking towards the United States [2], Canada, and other European countries such as the United Kingdom and the Netherlands for good examples to follow.

독일에는 약 8만명의 의과대학생이 있고, 36개의 의과대학(medical faculties)가 있다. 매년 1만명의 새로운 학생들의 의학의 길로 들어서며, 약 6000명의 학생이 매년 졸업한다. 의과대학의 지역별 분포는 인구밀도보다는 역사적 발전배경에 따른 것이다.

Germany has about 80,000 medical students studying in 36 medical faculties (Table 1 (Tab. 1), list with URLs see Attachment 1) [3]. Each year 10,000 new students start medical education and about 6000 students graduate every year. Geographic distribution of medical faculties in Germany reflects historic developments rather than population density (Figure 1 (Fig. 1)).

약 180,000유로(한화 약 2억5천만원)정도가 한 명의 의과대학생을 길러내는데 들어가며, 이는 영국의 260,000유로와 비교되곤 한다. 그러나 한 의과대학을 제외하고는 모두 주립대학이며, 최근까지 학부의학교육은 무상으로 제공되었다. 최근에서야 일부 주에서 학기당 500유로 정도의 등록금을 학생들에게 부담시키고 있으며, 미국에 비하면 매우 낮은 편이다. 학자금 대출도 가능하다.

It is estimated that 180,000 Euros are required to cover the cost of teaching for each graduating medical student in Germany [3]. This compares to 260,000 Euros in the United Kingdom [4]. All but one medical faculty (Witten-Herdecke) are state universities, and until recently higher (undergraduate) education was free – now a few states charge up to 500,- € tuition per semester which is low in comparison to fees required for example in the United States [5]. Grants and student loans are available [6].

이러한 배경을 놓고 볼 때, 이 논문의 목적은 "Regulation of the Licensing of Doctors"가 새롭게 도입됨에 따라 해외 독자들에게 독일 학부 의학교육의 구조와 교육과정, 조직에 대해 설명하고자 하는 것이다. 

Given this background, the aim of this article is to provide international readers with an overview of the organisation, structure and curriculum of undergraduate medical education in Germany following the introduction of the new "Regulation of the Licensing of Doctors". This narrative review is based on data available from official organisations, relevant German medical journals generally not listed in Medline or EMBASE, and on personal experience. It is therefore likely to serve as a reference for reports of research in medical education in Germany and could also help international medical staff seeking to assess medical students taught in Germany who are applying for elective clerkships abroad.

Structure and curriculum of medical education

The new regulation of the licensing of doctors

독일 의학교육은 2003년 도입된 Regulation of the Licensing of Doctors의 이후에 국제 학술지에 소개된 바가 없다. 이 개혁은 독일의 정부기관, 비정부기관 등에서 독일의 의학교육이 EU의 요구조건을 만족시키지 못하고 있다는 주장이 제기됨에 따라서 도입되었다. 독일에서 의학교육에 대한 관심은 네덜란드나 영국에 비해서는 낮은 편이지만 새로운 AppOA가 도입된 이후에 모멘텀을 얻고 있으며 교육과정에도 상당한 변화가 생겼다. 주요 변화는 다음과 같다.

German Medical Education has not been described in international journals since the new "Regulation of the Licensing of Doctors" [Approbationsordnung für Ärzte (AppOÄ)], which came into effect in 2003 [7], [8], [9]. This structural reform became necessary when reports from governmental and non-governmental institutions concluded that medical education in Germany did not meet actual requirements in medical care or stipulations from the European Union [10], [11]. While interest in medical education in Germany was relatively low compared to e.g. The Netherlands or the United Kingdom, it has now gained momentum with the new AppOÄ, which required substantial changes in the curriculum. The main changes are [8]:

• Incorporation of the changed requirements in medical care
• Linkage of theoretical and clinical instruction
• Extension of interdisciplinary and topic-related instruction
• Improvement of bedside training, reduction of lectures
• Reform of examinations
• Strengthening of General Practice
• Evaluation of teaching
• Improving pain management and palliative care

의과대학에 중요한 문제는 아니었을지 몰라도, 의과대학생들에게 있어서 가장 와닿는 변화는, 완전면허(full license)를 받기 위해 필요했던 18개월간의 인턴십(AiP)가 폐지된 것이다. 이 기간의 임금은 상당히 낮은 편이었다.

Although of limited importance to medical faculties, for graduating medical students the most tangible change represented the abolishment of the lowly paid 18-month internship [Arzt im Praktikum (AiP)] before obtaining the full license to practise medicine [12].

이 다음부터는 의과대학 교육과정에 대해 다루고자 한다.

In the following description of the medical curriculum and in the discussion, the main goals of the new AppOÄ will be referred to.

Admission criteria for medical students

매우 소수의 예외를 제외하고 독일고등교육적성인증(General Certificate of Aptitude for Higher Education, Abitur)은 대학의 고등교육을 받기 위해서 반드시 필요하다. 12~13년간 학교를 다녀야 하며, 약 39%의 학생이 Abitur를 획득한다. Abitur는 미국의 '고등학교 졸업장'에 해당하는 것은 아니며, 그보다는 US colleges의 학위와 비슷한 것이다. EU내에서의 Secondary school diploma는 상호 인정을 받을 수 있으나 EU 외 지역에서 diploma를 받은 경우에는 이것이 서로 동등한 것임을 증명하는 인증을 획득해야 한다. 일부 국가에서 주되게 활용되고 있는 의학에 있어서의 undergraduate education(prepatory class, 우리나라의 의예과 개념인 듯)은 독일에서는 존재하지 않으며, 따라서 엄밀히 말하면 undergraduate 또는 graduate education이라는 개념은 옳지 않다.

With few exceptions, the General Certificate of Aptitude for Higher Education [Abitur] is a prerequisite for admission to higher education in a university. It usually requires 12 or 13 years of schooling. Roughly 39% of all school children will obtain the Abitur [13]. The Abitur cannot be compared to a high school diploma in the United States; it is closer to the associate degree of US colleges. Secondary school diplomas obtained inside the European Union are mutually recognised; however students with diplomas obtained outside the European Union have to apply for a certificate of equivalence. Undergraduate education e.g. preparatory classes for medical school, prevalent in some countries, do not exist in Germany. Therefore, the term undergraduate or graduate education does not apply in the strict sense.

독일에서 의과대학 신입생의 평균 연령은 21.4세이며, 여기에는 몇 가지 이유가 있는데 독일 남성들에게는 9개월간의 군복무 의무가 부과된다.(양심적 병역거부자(conscientious objectors)들은 대체민간봉사(alternative civilian service)한다.) 다른 분야에서의 professional training을 받는 경우 또는 waiting time으로 인한 이유도 있다. 공식적 규제는 없으나 40세가 의과대학 입학의 상한선으로 간주되고 있으며, 다른 많은 국가와 마찬가지로 의과대학의 여학생은 빠르게 증가하여 이제는 남학생보다 그 수가 많아졌다. 

In Germany, the average age of medical students is 21.4 years when they start medical school [14]. There are several reasons for this. Germany still has mandatory service of nine months for men either in the military or an alternative civilian service [Zivildienst] for conscientious objectors. Additionally due to waiting time or professional training in other areas, a significant proportion of students are older. Although there is no formal regulation, an age of 40 years is considered the upper limit for entering medical school. Similar to many other countries, the number of women studying medicine has increased steadily and is now exceeding the proportion of male students [15]. This however is not yet reflected in higher academic ranks.

Selection of medical students

의과대학에 지원하는 지원자의 수는 정원보다 훨씬 많아 입학 정원이 제한되어 있다. 평균적으로 4~5:1정도의 경쟁률이 되나, 대학마다 차이가 크다. 독일에서 의과대학 지원과 선발은 ZVS라는 중앙 국가 기관에 의해서 운영된다. 입학 기준으로는 Abitur grade(미국의 GPA에 해당)와 대기시간(waiting time)이 있다. Abitur는 교육과정을 성공적으로 마칠 것인가에 대한 가장 좋은 예측인자이다. 각 학생은 한 번에 6개까지 의과대학에 1순위부터 6순위까지 지원을 할 수 있으며, 대부분의 의과대학 학생은 이러한 절차를 거쳐서 입학하게 되나, 일부 해외 학생이나 군(military)를 위한 정원이 있다.

The number of applicants to medical schools largely exceeds the number of available places; therefore admission is subject to restrictions [numerus clausus]. On average four to five prospective students apply for each place, however there are large differences between the faculties. In Germany, application to medical schools is administered by a federal organisation, the Central Office for the Allocation of Places in Higher Education [Zentralstelle für die Vergabe von Studienplätzen (ZVS)] [16]. Criteria for admission are the overall Abitur grade, which is roughly comparable to the American Grade Point Average (GPA), and waiting time. The Abitur is considered the best predictor for successful completion of the curriculum [17]. Each student can rank and apply to 6 medical schools at once. The majority of medical students (80%) used to be admitted by this process and there is a quota for foreign medical students and the military.

의과대학에 의해서 자체적으로 선발되는 학생의 비율은 60%까지 증가하였다.(?). 대부분의 학생은 의과대학에 지원동기를 제출하는데, 의과대학에서는 이 지원서를 살펴본 후에 일부 학생을 대상으로 면접을 한다. 그러나 종종 이 단계는 시간이 굉장히 많이 소모되며 지원자의 수가 너무 많은 때도 있다. 따라서 의과대학에서는 교수들에게 이 과정에 참여하라고 독려하기가 쉽지 않다. 또한 미래 의사가 될 학생을 선발하는 criteria에 대한 합의가 없는 경우도 있다. 이러한 상황에서 TMS라는 국가적 의과대학입학시험은 1997년 폐지되었으나 일부 의과대학에서 다시 도입되기도 하였다. TMS는 미국의 MCAT에 비유될 수 있으며, TMS가 의무사항은 아니지만 선발 단계에서 면접대상자로 뽑힐 가능성을 높여주는 면은 있다.

The proportion of students who are selected by the medical schools themselves is supposed to increase to 60%. Usually students apply with a letter of motivation to medical schools. After screening the applications a few are invited for interview [18]. However the process is time consuming and sometimes the number of applicants is overwhelming. Therefore faculties find it difficult to motivate faculty members to participate in the selection process. There is also often no consensus on the criteria that should be used to select future doctors. Given this situation, the nationwide medical admission test [Test für Medizinische Studiengänge (TMS)], which had been abandoned in 1997, has been reintroduced by some faculties [19]. The TMS is comparable to the American Medical college admission test (MCAT) [20]. The TMS is not mandatory but allows students to improve their score and their chance of being selected to come for an interview.

Structure of the curriculum

독일에서 의학교육은 다른 많은 국가가 '연' 단위로 되어있는 것과 달리 '학기'단위 또는 일부 경우 '3분기(trimester)' 단위로 구조화되어있다. 교육과정을 마칠 때 까지는 총 6년(12학기)+3달이 걸리며 평균적으로는 6.8년정도 학교를 다닌다. 교육과정은 크게 세 섹션으로 나뉜다.

In Germany, medical education is structured, not in years like many other countries, but in semesters or in a few instances, trimesters (Hamburg, Hannover). It takes six years (12 semesters) and three months to complete the curriculum, however on average, students require 6.8 years [3]. The curriculum is divided into three sections (Table 2 (Tab. 2)):

• Basic science (2 years)
• Clinical science (3 years)
• Clinical year (1 year)

대다수의 학생은 이 단계를 따르게 되며, 일부 의과대학은 실험적 교육과정을 운영하기도 한다.

The majority of medical students follow this track. Some medical faculties have chosen to offer an experimental curriculum [Modellstudiengang] which offers an alternative process to becoming a doctor (Table 1 (Tab. 1)) [21].

Basic science [Vorklinik] 

기초의학 과정의 내용과 구조는 거의 변화가 없으며, 주 과목은 해부학, 생리학, 생화학, 사회과학이다. 대부분 Pass또는 Fail로 평가한다. 기초의학과 임상의학 사이의 간극이 비판을 받고 있는데, 졸업생들은 이 기초과학 내용이 임상에서 거의 쓸모가 없다고 평가하고 있다. 따라서 기초과학을 임상적 맥락에서 교육하기 위한 노력이 지속적으로 이뤄지고 있으며, 3달간의 nursing stage가 기초의학 부분에서 의무적으로 운영되고 있다. 그러나 추가적인 준비과정을 운영하고 있는 사립 기관(private institutions)이 점차 증가하고 있으며, 이는 의사국가시험을 합격하기에 충분한 교육이 이뤄지지 못한다는 것을 의미한다.

The content and structure of the basic science section (also preclinical science) has remained largely unchanged. The main topics are anatomy, physiology, biochemistry and social sciences (Table 2 (Tab. 2)). Courses are usually not graded beyond pass or fail. The distinction between clinical and basic science has been criticised and graduate students have rated large parts of the curriculum as clinically irrelevant [22]. Therefore there are increased efforts to place basic science in a clinical context [23], [24]. A three month nursing stage is a mandatory part of the basic science section to ensure first patient contact. However private institutions are increasingly offering additional preparatory classes, which might indicate the failure of the faculties to provide the necessary skills and knowledge to pass the state medical licensing examinations.

Clinical science [Klinik] 

임상과학은 21개의 전공과목을 포함하며, 예전에는 각각의 과목을 개별적으로 가르쳤다. 그러나 이제는 여러 과목을 학제간교육모듈(interdisciplinary teaching modules)로 교육하고 있어서 "head module"에서는 귀, 코, 목, 안과 등을 같이 다룬다. 추가적으로 12개의 학제간교육모듈이 도입되었으며, 대체로 첫 해에는 임상과학의 도입부분으로 병력청취와 신체검진의 기본 기술을 익힌다. 또한 일반 병리학, 일반 미생물학, 일반 약리학, 실험의학 등을 배운다. 전통적으로 임상과학 교육과정은 환자 노출이 별로 없고 강의와 세미나로 진행되었는데, 임상경험을 강화시키기 위해서 의무적 임상실습이 내과, 일반외과, 소아과, 산부인과, 일반과(General Practice) 과목에 도입되었다. 정신과학이 대부분의 국가에서 핵심 과목으로 다뤄지는 것과 달리 독일에서는 의무가 아니다. 임상술기실습(Clinical skill lab)이 여러 대학에서 도입되었으며, 학생은 한달짜리 elective clerkship을 선택할 수 있다. 한 개의 clerkship은 외래에서 진행되어야 한다. 

The clinical science section covers 21 medical specialties as listed in Table 2 (Tab. 2). Previously each subject was taught separately. Now subjects are often taught in interdisciplinary teaching modules e.g. a “head module” combining Ear, Nose & Throat Medicine with Ophthalmology [25]. Additionally 12 new interdisciplinary teaching modules [Querschnittsbereiche] have been introduced (Table 3 (Tab. 3)). Usually the first year is dedicated to the introduction of the clinical sciences with basic skill training in history taking and physical examination, general pathology, general microbiology, general pharmacology and laboratory medicine. Traditionally the clinical science section consisted mainly of lectures and seminars with limited patient exposure. To strengthen clinical experience, mandatory clerkships [Blockpraktikum] have been introduced in Internal Medicine, General Surgery, Paediatrics, Obstetrics & Gynaecology and General Practice. It is notable that a clerkship in Psychiatry, which is considered a core subject in many countries, is not mandatory. Clinical skills labs have been newly established in most faculties [26]. Additionally students have to complete four one-month elective clerkships, traditionally called Famulatur [famulus latin: servant]. One clerkship has to be completed in the ambulatory setting. It is very popular to perform at least one elective outside Germany with a preference for English speaking countries.

Clinical year [Praktisches Jahr: PJ] 

마지막 학년은 세 개의 full-time clinical rotation으로 구성되어 있으며 각각은 4달씩 진행된다. 내과와 외과 rotation은 의무적으로 들어가야 하며, 한 개는 임상과들 중 자유롭게 고를 수 있다. 예전에는 마지막 학년은 병원을 중심으로 훈련을 받아야 했지만 새로운 AppOA에서는 외래 기반 세팅에서도 실습이 가능해졌다.

The final year is divided into three full-time clinical rotations, each lasting about 4 months (Table 2 (Tab. 2)). Rotations in Internal Medicine and Surgery are mandatory and one rotation can be freely chosen from all the clinical specialties. Previously, the final year had been restricted to hospital based training sites. The new AppOÄ made it possible for the first time to complete a clinical rotation in an ambulatory setting, e.g. in General Practice [27].

마지막 학년 내에서도 학생은 점차 더 많은 책임을 지게 되는데, 이는 서브인턴십과 비슷한 것이다. 법적인 문제들이 학생들이 직접 자신이 해볼 수 있는 임상 경험을 쌓는데 제한이 되고 있다. 혈액 채취나 IV line을 잡는 것은 대부분의 국가에서 AN에 의해서 이뤄지지만, 독일에서는 이런 일 때문에 최종학년 학생(PJler)들이 바쁘다. 일반적으로 학생들이 임상현장에서 배우는 것을 당연하게 받아들이지만, 감독과 지시의 수준은 무척 다르다. 

Students usually assume more responsibilities gradually during the final year, comparable to a sub-internship. Legal 

issues regarding delegation and liability limit students’ opportunity to gain hands on experience [28]. Hospitals often rely on the work accomplished by the final year students [PJler]. Unfortunately, taking blood samples and inserting intravenous lines, which is done by auxiliary nurses in most other countries, keeps PJ students busy [29]. It is generally taken for granted that students learn skills on the job, but the degree of supervision and instruction varies widely [30]. Multiple projects to improve the quality of teaching in the clinical year have been presented and only a few can be cited here [31], [32].

스위스에서 독일어를 사용하는 지역에서는 최종학년 학생들에게 일정부분의 보상을 지급하고, 이렇게 보상을 지급하는 것에 대한 논쟁이 있다. 의사 부족이 점차 심해지면서 일부 교육병원(teaching hospital)에서는 학생들을 졸업 후 수련과정에 유지시키기 위해 특별히 노력을 기울이고 있다.

As the German-speaking region of Switzerland offers a basic remuneration to final year students, there is a debate as to whether students should be paid. With the increasing shortage of physicians, some teaching hospitals are known to make special efforts to retain some students for postgraduate training.

Examinations

새로운 AppOA가 도입되기 전까지는 의과대학생의 학업성취도는 pass/fail로 평가되었고, 면허시험만이 점수를 주게 되어 있었다. 대학의 입장에서 새로운 regulation이 불러온 가장 큰 변화는 (1)각각의 교과목과 임상실습에 대한 grade를 매겨야 하는 것, (2)면허시험을 3단계에서 2단계로 축소시키는 것이었다. Grade는 1(excellent)에서 5(fail)까지 순위로 매겨진다.

Until the new AppOÄ, the achievements of medical students in courses and clerkships were evaluated simply with a pass or fail. Only state licensing examinations were graded. From the faculties perspective the most radical changes with the new regulations for medical education were 1. the requirement to grade each course and clerkship and 2. the reduction of the number of licensing examinations from three to two. Grades are given on an ordinal scale ranging from 1 (excellent) to 5 (fail).

대학의 책임을 강화하는 것이 가져온 효과는 다양한데, 기존의 대학은 시험에 최소한의 노력만을 기울였고, 여기에 노력을 쏟는 것은 주정부(state authorities)에 의해서 운영되는 면허시험이었다. 면허시험을 치르기 위한 인증(certificate)를 받기 위해서 학생들은 공식적 평가과정을 밟지 않거나 매우 조금만 밟아도 되었고, 대부분 출석만 잘 하면 인증을 받을 수 있었다. 해부학과 같은 소수의 과목에서만 시간을 들여서 구두시험을 치렀다. 과거에는 최종 면허시험이 유일한 summative grade였다.

Strengthening the responsibility of faculties had mixed effects. Previously faculties invested only a minimal effort with respect to examinations. This was left to the centrally organised state licensing examination administered by state authorities [Landesprüfungsamt]. Students received certificates [Scheine] with little or no formal assessment in each of the subjects required in order to register for the licensing examinations. Most often physical attendance during the course was sufficient to obtain the course certificate. Only a few subjects such as anatomy required time consuming oral examinations. Previously, on the final licensing examination certificate only one summative grade of the written multiple choice exams and the final oral examination appeared on the diploma.

이제는 각각의 과목이 반드시 grade로 평가되고 최종 학위에 표기되어야 한다. 한편으로 이러한 정책은 OSCE와 같은 평가법의 도입을 유도했고, 다른 한 편으로 이러한 시험을 도입하는 것이 작은 교실에서는 상당한 부담을 가져왔다. 예를 들어 psychosocial science 학과 등에서는 수용능력을 초과하는 구두시험은 치를 수가 없게 되었다.

Now each subject must be graded and appears on the final diploma. On the one hand this has led to the introduction of modern assessment tools to evaluate practical skills like the objective structured clinical examination (OSCE) in several faculties [33]. On the other hand time and staff consuming examinations turned out to be a burden especially for smaller departments. For example psychosocial sciences in the preclinical section had to stop administering oral exams exceeding their staff capacities.

새로운 면허시험은 다지선다형 필기시험과 구두시험으로 구성되어 있다. MCQ의 개발은 IMPP가 주관한다. 대학별로 나름의 교육과정이 있으나 IMMP는 필기시험에서 다뤄지는 주제의 카탈로그를 가지고 있다.

The new licensing examination consists of a written test with multiple choice questions (MCQs) and an (unstructured) oral examination. The administration and development of MCQs continues to be organised by the Institute for medical and pharmaceutical examination questions [Institut für Medizinische und Pharmazeutische Prüfungsfragen (IMPP)] [34]. Although each medical faculty has its own curriculum, the IMMP has a catalogue of topics covered by the written exams [Gegenstandskatalog].

면허시험의 앞 파트는 예전에 Physikum이라 불리던 것으로서 임상실습을 하기 위해서 이 시험을 반드시 통과해야 한다. 약 20%정도의 학생이 탈락하며, 두 차례까지 볼 수 있다. 5%학생이 결국 탈락하게 되며, USMLE step1에 해당하는 시험은 아니다.

The first part of the medical licensing examination [Erster Abschnitt der Ärztlichen Prüfung], traditionally called “Physikum”, is the first hurdle students have to take. In order to proceed to the clinical section, this examination must be passed. The average initial failure rate is roughly 20%. The examination can be repeated twice; about 5% of all students never pass. This exam is not equivalent to the USMLE step 1 (United States Medical Licensing Examination).

면허시험의 새로운 두 번째 파트는 Hammerexamen이라 불리며, 괴물시험(monster exam)이라고 번역할 수 있다. 이는 기존에 별개였던 세 개의 시험을 대체하는 시험으로 임상과학의 전체적인 스펙트럼을 모두 포괄한다. 필기시험과 구두+실기시험이 합해진 시험으로 구성되는데, 이 시험의 별명(괴물시험)이 말해주는 것처럼, 필기시험의 탈락율이 2%에서 9%로 치솟았다. 구두+실기시험을 탈락하는 학생은 적으며, 이는 이 시험에 대한 비판중 한 가지이다. 

The new second part of the medical licensing examination [Zweiter Abschnitt der Ärztlichen Prüfung] of the clinical year has colloquially been termed “Hammerexamen” which can roughly be translated as “monster exam”. It has replaced three previously separate examinations and covers the entire spectrum of the clinical sciences. It consists of a written exam and a combined oral and practical exam. This exam lives up to its nickname since the previously low failure rate associated with the written part rocketed from 2% to 9%. Only a few students fail the oral and practical examination, which is only one of several reasons that this exam format has been criticised [35]. 

학생들이 '괴물 시험'에 대한 준비에만 초점을 맞추다가 임상실습과 학습에는 소홀해진다는 비판도 있다. IMPP가 필기고사 문항을 드문 질환 위주로 만들면서 더 통합적이고 임상적으로 중요한 것을 소홀히한다는 의견도 있다. 비록 새롭게 도입된 사례중심 문항형식이 MCQ 문항을 많이 발전시켰다고 보기도 하지만, 의학적으로 특이한 사례를 암기하고 별로 중요하지 않은 사실들을 아는 것이 여전히 중요한 부분으로 남아있다.

It is also felt that final year students are less well prepared than previous generations who took the last written examination before entering the clinical year. It is suspected that students focus on preparing for the “monster exam” and are distracted from clinical practical work and learning [36]. It had been hoped that the tendency of the IMPP to create multiple choice questions around rare syndromes would be abandoned in favour of more interdisciplinary and clinically relevant topics. Although the new case-based format still consisting of multiple choice questions is considered a significant improvement, remembering medical oddities and irrelevant facts still remains important [37].

Ranking of medical faculties

독일에서 의과대학의 순위는 상대적으로 새로운 것으로, The German Academic Exchange Service는 연구/시설/학생평가 등등을 기준으로 평가를 하였다. 면허시험에서의 학생의 수행능력을 기반으로 한 평가도 가능하다. 

Ranking of faculties is rather new in Germany and, as elsewhere, dependent on the selection criteria. The German Academic Exchange Service has ranked medical faculties in various topics including research, infrastructure and student evaluation [38]. Ranking based on students’ performance in state licensing examination is also available [39]. Adjustment for differences in allocation of resources per capita or the proportion of foreign medical students has a significant impact on ranking.

Title

최종 면허시험을 통과한 학생은 의술을 행할 수 있는 면허가 주어지나 academic title이 붙은 academic degree는 주어지지 않는다. 졸업생들은 Arzt라는 전문직 타이틀을 쓸 수 있으나, 비공식적으로 일반적으로는 "Dr."라고 불리기도 한다. 다른 나라와 마찬가지로 학위논문을 쓰는 것이 "Dr.med"를 받기 위해서 필요하다. 70%의 졸업생이 학위논문을 마무리짓는다고 나오며, 이는 이것이 진로/승진과 환자 유인에 유리하기 때문이다.

A student who passes the final licensing examinations is awarded a license to practice medicine [Approbation als Arzt], but does not receive an academic degree with an academic title [40]. Graduates are authorised to use the German professional title Arzt/Ärztin (Physician), but are generally addressed informally with the honorary title "Dr." [Doktor]. As in other countries, writing a dissertation/thesis is an option required to obtain the academic degree “Dr. med.”. It is estimated that 70% of all graduates will eventually complete a dissertation, which is perceived to be important for career promotion and to attract patients [41].

Discussion

Implementation of reforms in medical education

Excellent doctors are the result of an excellent medical education. The new "Regulation of the Licensing of Doctors (AppOÄ)" has certainly fostered important improvements in the education of medical students in Germany. The increased interest in medical education is documented by the dynamic development of the German Society for Medical Education [Gesellschaft für Medizinische Ausbildung] [42] and the introduction of the first postgraduate Master of Medical Education (MME) programme in Germany in 2005 [43]. Previously the only German-speaking MME-program was offered by the University of Bern in Switzerland.

It is uncertain if the goals of the new AppOÄ have been achieved as there are no official reports available. However, some professional organisations have conducted surveys.

Strengthening the role of General Practice in the face of an anticipated shortage of general practitioners was one of the multiple goals of the reform. Although some faculties have founded new Departments of General Practice, more than half of all faculties have no such department [44]. Similarly the stipulated strengthening of palliative care and pain management has also not yet been achieved in all faculties [45]. A national survey of teaching in Geriatrics, which had not previously been a component of the curriculum but is now covered by a mandatory interdisciplinary teaching module “Medicine of aging and the elderly”, revealed that less than half of all medical faculties provide teaching in this topic [46].

Mandatory evaluation of teaching was also among the aims of the AppOÄ. The main purpose of evaluation is quality control but also distribution of funds [47]. The last national survey on the evaluation of medical teaching in Germany was performed in 2000 before the reform [48]. Multiple evaluations of courses have been reported (selected examples [49], [50]) however there is no national standard and reporting bias is likely.

Unlike other university programmes awarding degrees to students, medical faculties in Germany are not subject to formal mandatory accreditation and reaccredidation procedures, since the final degree is a license awarded by the state. Although the German Council of Science and Humanities [Wissenschaftsrat] [51] has evaluated medical faculties, it is left to the discretion of the states as to how to ensure compliance with the stipulated requirements [52]. So far only one faculty has been on probation in 2005. It is conceivable that the states, which are responsible for funding medical faculties, have a conflict of interest given that external accreditation might reveal deficiencies due to under-funding.

Barriers to the implementation of stipulated reforms

Enacting the new AppOÄ was a pure administrative act and unfortunately was not provided with a budget to ensure its implementation [53]. Medical faculties are facing incredible difficulties to fulfil all the new requirements. The reduction in the number of lectures and rise in bedside teaching has increased the need dramatically for both clinical teachers and available patients. Although lip service is paid to the commitment for medical education, young academics are not rewarded for their efforts, and teaching, which must compete with research and patient care, is sometimes considered a lost cause [54].

At the same time, virtually all university hospitals to which medical schools are attached are in serious financial crisis, partly due to a new invoicing system and budget cuts [55]. Some of the previously state-owned university hospitals have been privatised (e.g. Giessen and Marburg) or transformed into foundations (e.g. Göttingen). This has increased the already pressing need for separate accounting of patient care financed by hospital revenues and teaching, and research covered by state grants or third-party funds. This has turned out to be extremely difficult since a significant proportion of the faculty is actively involved in both [56]. Only a few medical faculties (e.g. Kiel/Lübeck, Dresden/Leipzig) are administered completely separately from university hospitals [57]. The funding of medical education has been described in more detail elsewhere [58].

European perspective

In 1999, the Education Ministers from 29 European countries including Germany adopted the Bologna declaration [59]. The principal goals of this were to permit easily readable and comparable university degrees within Europe and to introduce a system essentially based on two main cycles, undergraduate and graduate, thus increasing mobility within Europe. In fact the mobility of medical students is already hampered at a national level by the multitude of non-compatible curricula although the Bologna declaration should also theoretically apply to medical education. However, this idea is neither encouraged by the German Medical Association nor some other medical associations [60]. The main reason to reject the implementation of the Bologna declaration for medical training is the fear of introducing a fast track “barefoot doctor”.

Conclusion

Improving and adapting education of medical students to the health needs of the population is a continuous process. The new "Regulation of the Licensing of Doctors (AppOÄ)" in Germany has stimulated multiple excellent projects to help future doctors meet these needs, but there is evidence that some of the stipulated changes have not been implemented. This review is an initial attempt to assess the compliance with the requirements of the AppOÄ and the success of the changes stipulated therein. Unfortunately it has not been possible to do justice to the educational activities in all 36 faculties, and while it is recognised that only a few selected projects have been discussed here, it is clear that mandatory external accreditation and periodic reaccreditations of medical faculties needs to be established in Germany [61].

List of abbreviations used

• AppOÄ: Approbationsordnung für Ärzte [Licensing Law for Medical Doctors]
• GPA: grade point average
• IMPP: Institut für Medizinische und Pharmazeutische Prüfungsfragen [Institute for medical and pharmaceutical examination questions]
• MCAT: Medical College Admission Test
• MCQ: multiple choice questions
• PJ: Praktisches Jahr [final year in medical school]
• TMS: Test für Medizinische Studiengänge [Test for medical education]
• USMLE: United States medical licensing examination
• ZVS: Zentralstelle für die Vergabe von Studienplätzen [Central office for the allocation of places in higher education]

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Ger Med Sci. 2009 Apr 2;7:Doc02. doi: 10.3205/000061.

Undergraduate medical education in Germany.

Chenot JF.

Author information

Abstract

The purpose of this article is to give international readers an overview of the organisation, structure and curriculum, together with important advances and problems, of undergraduate medical education in Germany. Interest in medical education in Germany has been relatively low but has gained momentum with the new "Regulation of the Licensing of Doctors" which came into effect in 2003. Medical education had required substantial reform, particularly with respect to improving the links between theoretical and clinical teaching and the extension of interdisciplinary and topic-related instruction. It takes six years and three months to complete the curriculum and training is divided into three sections: basic science (2 years), clinical science (3 years) and final clinical year. While the reorganisation of graduate medical education required by the new "Regulation of the Licensing of Doctors" has stimulated multiple excellent teaching projects, there is evidence that some of the stipulated changes have not been implemented. Indeed, whether the medical schools have complied with this regulation and its overall success remains to be assessed systematically. Mandatory external accreditation and periodic reaccreditation of medical faculties need to be established in Germany.

KEYWORDS:

Germany; reform; undergraduate medical education