오스트리아에서 입학시험(Admission Test) 도입 전과 후의 의과대학생의 탈락율(Dropout rate)비교

Dropout Rates in Medical Students at One School Before and After the Installation of Admission Tests in Austria

Gilbert Reibnegger, DSc, Hans-Christian Caluba, Daniel Ithaler, Simone Manhal, Heide Maria Neges, and Josef Smolle, MD

2002-2003학년도에 오스트리아의 의학교육에는 근본적 변화가 생겼다. 전통적인, 학문 중심의 교육 프로그램이 근대적인(modern), 주제별(theme-based), 학위수여(diploma-granting) 교육과정으로 변한 것이다. 오스트리아에 있는 모든 세 개의 공립 의과대학이 이 변화를 수용했으나, 각각의 대학은 세부적인 사항에 대해서는 학교별 강점과 선호에 따라 자율적으로 조정하였다.

In academic year 2002–2003, medical education in Austria changed in a fundamental way. The traditional, discipline-oriented study program was transformed into a modern, theme-based, diploma-granting curriculum with a timely, module-track structure. Although all three public medical universities in Austria (Medical University of Vienna, Innsbruck Medical University, and Medical University of Graz) adopted this reform in general, each university was free in establishing the details of its curriculum according to its specific strengths and preferences.

Background

Graz의과대학 교육과정

The Medical University of Graz curriculum

Graz의과대학의 교육과정은 처음부터 전임상 주제와 임상 주제를 통합하는 형태였으며, 조기에 환자 경험을 쌓는 것은 사회적, 의사소통 능력 뿐만 아니라 신체검진 능력 향상에도 도움이 된다. 또한 과학적 연구에 대한 교육도 강화했으며, 새롭게 설계된 'clinical year'가 역시 교육과정의 특징이다.

The reformed curriculum at the Medical University of Graz 1 integrates preclinical and clinical topics from the beginning. Early patient contact strongly enhances training in physical examination skills as well as social and communication skills. In addition, better education in scientific research matters and a newly designed “clinical year” are the hallmarks of the new program. The curriculum is designed to be completed in six years.

처음의 두 학기는 "첫 부분"으로서 의학 맥락 속에서 기초과학을 주로 배우게 된다. "두 번째 부분"은 2학년부터 5학년까지로, 의학지식의 기초, 정상과 병리상태, 형태학, 다양한 의학/임상 학문 등등을 배우게 된다. 첫 번재와 두 번째 부분은 주제별로 5주간 진행되는 형태이다. 30개 모듈 중에서 25개 모듈은 의무이며, 5개 모듈은 선택할 수 있다.

The initial two study semesters, the “first part of study,” are dominated by the basics of natural sciences in a medical context. The “second part of study,” years 2 through 5, is devoted to the fundamentals of medical knowledge, including normal as well as pathological function and morphology and the various medical and clinical disciplines. The first and second parts of study are organized in theme-centered modules lasting five weeks each. The modules are accompanied by vertical “tracks.” In tracks, specific knowledge and skills are taught during consecutive study years. Students choose 5 out of the required 30 modules from a broad offering of elective modules; 25 modules are obligatory for all students.

6학년에는 학생들은 다양한 임상 현장에서 임상현장의 일상에 참여하게 되며, 전문적인 임상 교사(expert clinical teacher)에 의해서 관리감독을 받게 된다.  또한 6학년 기간에 5주는 general practitioner의 office에서 보내게 된다.

In year 6, students participate in the daily clinical routine at different training sites and are constantly guided and supervised by expert clinical teachers. Additionally, during the course of year 6, students also spend five weeks in a general practitioner's office.

 

오스트리아의 의과대학 입학

Medical school admissions in Austria

일반적으로 오스트리아 대학은 'open admission'을 따라왔다. 즉, 고등학교를 성공적으로 마친 학생은 누구나 자신이 원하는 어떤 대학에든 입학할 수 있다는 것이다. 그러나 의과대학에 있어서 이러한 '개방입학(open admission)'은 상당히 만족스럽지 못한 결과를 가져왔다. 예컨대, Graz의과대학의 경우 의과대학 신입생은 600~800명으로 매년 다르며, 이 숫자는 교수 뿐만 아니라 시설 측면에서 학교의 수용능력을 넘어서는 것이다. 따라서 학습 환경이 좋지 못하고, 의욕이 꺾인 학생과 교수들은 소규모 학습 따위는 거의 하지 않으며 대부분의 수업이 대형 강의로 진행된다. Bedside teaching도 거의 없다. 학생들은 의과대학이 6년제 교육과정임에도 평균적으로 50%(3년) 이상을 추가적으로 학교를 다니고 있으며, 약 절반의 학생은 졸업하기 전에 탈락(dropped out) 한다.

In Austria, open admission to university studies has been the rule: Everyone successfully finishing secondary school education is generally entitled to be admitted to whatever university study she or he wants. In medicine, open admission led to particularly unsatisfactory consequences. For example, at the Medical University of Graz, the average number of new medical students varied between 600 and 800 per year, substantially exceeding capacities in terms of staff as well as infrastructure. Thus, study conditions were poor. Frustrated students and faculty made do with little or no small-group lecturing, a predominance of mass lectures, and little bedside teaching, among other limitations. On average, students exceeded the scheduled study time of six years by 50% or more, and approximately half of the students dropped out before reaching graduation.

오스트리아 의과대학은 또한 오스트리아 외 국가에서도 학생을 받아왔는데, 역사적으로 오스트리아의 대학에 입학하는 다른나라의 학생들(EU 국가 포함)은 자신의 국가에서도 동등하게 대학에 입학하였다는 것을 입증하여야 한다. 그러나 유럽법(European law)에 따르면 EU국가의 모든 시민들은 오스트리아 대학에 지원할 때 오스트리아 국민과 동등한 대우를 받아야 하고, 2005년 7월 European court는 오스트리아의 외국 학생에 대한 정책이 위법이라는 판결을 내렸다. 

Austrian medical universities also admitted students from outside Austria. Historically, students from other countries—including member states of the European Union (EU)—were admitted to an Austrian university only after they proved they had also been admitted to the same course of study in their country of origin. According to European law, however, citizens from all EU member states must be treated in the same way as Austrians when applying to Austrian universities. In July 2005, the European Court ruled that Austria's policy of foreign student admission to university studies violated European law.2 

이러한 결정은 의과대학에 특히 결정적이었다. 독일은 오스트리아의 인접국이면서, 오스트리아와 같은 언어를 사용하는데, 독일에서는 30000명의 의과대학 지원자 중 8000명~10000명만 의과대학에 입학할 수 있었던 것이다. European Court의 판결 이후 세 개의 오스트리아 의과대학이 독일 학생들로 꽉꽉 찰 것이라는 우려가 상당했다. 이에 대한 대책으로서 오스트리아 법이 즉각적으로 개정되었는데, 대부분의 대학 입학에 대해서는 여전히 개방입학(open admission)으로 남겨놓았지만, 일부 학과에 대해서는 입학 시험을 도입하는 것으로 바뀌었고, 이러한 학과에는 의학과 치의학 학위 프로그램이 포함되었다. 또한 European Commission은 2007년부터 5년간 오스트리아로 하여금 학생의 정원을 통제할 수 있도록 하였으며, 대부분의 의과대학 정원은 오스트리아 국민에게 가도록 하였다. 전체 정원중 75%는 오스트리아 자국민에게 할당되었으며, 20%는 다른 EU국가, 5%는 그 외 다른 국가에게 분배되었다.

This decision was particularly important for medical universities because of circumstances in Austria's neighboring country, Germany, which shares the same language as Austria. In Germany, only 8,000 to 10,000 of the approximately 30,000 applicants for the study of medicine are admitted each year. Therefore, after the court's decision, it was feared that the three Austrian medical universities would be overwhelmed by German students. To avoid this, Austrian law was changed immediately: While admission to most university study programs remained open for all applicants having completed secondary education, admission tests were introduced to regulate access for selected studies. Among the regulated studies were the diploma programs in human medicine and dentistry. Additionally, the European Commission issued a five-year moratorium in 2007,3 entitling Austria to regulate quotas of students until 2012 to ensure that the majority of openings are reserved for Austrian citizens. Seventy-five percent of openings are reserved for applicants who completed their secondary education at an Austrian school, 20% for citizens from other EU states, and 5% for applicants of other nationalities.

 

Graz의과대학의 선발

Medical University of Graz admissions

 

2005년, Graz의과대학은 난관에 봉착했는데, 이 전 년도의 개방입학에서 지나치게 많은 학생들이 입학한 것이다. 또한 2002-2003학년도에 도입된 새로운 교육과정은 이 전 교육과정에 비해서 더 많은 자원이 투입되어야 했다. 이러한 상황에서 '첫 파트'를 성공적으로 이수한 학생들도 즉각적으로 '두 번째 파트'로 진학하지 못하는 문제가 생겼다.

In 2005, the Medical University of Graz faced an unfortunate state of affairs. Because of the open admission policy of previous years, there was an inordinate number of students enrolled in the diploma of human medicine program. Further, the new curriculum implemented in 2002–2003 required significantly more resources than the previous program. Under these circumstances, students who had successfully completed the first part of study could not immediately proceed with the second part because of a lack of resources.

 

이러한 상황을 해결하기 위해서, 의과대학에서는 두 가지 당시의 법적 상황을 활용하여서 새롭게 입학하는 학생의 숫자를 조절하였다. 이에 따라 2005-2006학년도에는 107명의 학생만이 새롭게 입학하였고, 그 다음 해에는 154명, 그 다음 해에는 282명으로 서서히 그 수가 증가하였다. 이러한 방식으로 Graz의과대학은 성공적으로 학생이 누적되는 문제를 해결하였다. 2008-2009학년도 이후에는 약 350명의 학생이 입학하고 있으며, 이것이 거의 상한선에 해당한다. 

To resolve this situation, the university used the new legal situation to manage the numbers of new students entering the university very efficiently. Thus, in academic year 2005–2006, only 107 new students were admitted. In the two following years, the numbers were raised incrementally (154 in 2006–2007, and 282 in 2007–2008). By this measure, we successfully eliminated the backlog of students waiting to continue their studies. Since 2008–2009, 340 to 350 students have been admitted per year, representing the upper limit of capacity. This upper limit was consensually defined with the Federal Ministry of Science and Research on the basis of previous experience.

입학 과정을 개선하기 위해서 두 가지 과정이 진행되었는데, 첫 번째로 2005-2006학년도에 1000명이 넘는 모든 지원자를 모두 임시합격시켜서 첫 학기를 이수하게 하였으며, 이 때애는 거의 인터넷을 활용한 원거리학습을 사용하였다. 첫 학기의 세 개 모듈은 모두 전자문서형태로 변환되었고, 'Graz의과대학가상캠퍼스'를 통해서만 제공되었다. 이는 종합적, 웹기반 학습 플랫폼으로 Graz의과대학에서 이전에 개발된 것이다. 2006년 1월에 임시 합격한 모든 지원자는 2일간의 선발 절차를 통과해야 하는데, 제1일에는 세 모듈에 대한 다지선다형 필기시험을 치르며, 제2일이에는 추가적은 다지선다형 시험을 통해서 생물, 화학, 물리, 수학에 대한 고등학교 수준의 지식을 평가한다. 최종 합격은 성적순으로 107명을 선발하며, 이 학생들이 최종입학하여 향후 의과대학 수업을 받게 된다. 다른 모든 학생들은 탈락된다.

Two different procedures were applied in our efforts to reform the admission process. First, in academic year 2005–2006, all applicants (more than 1,000) were preliminarily accepted for an initial semester, which entailed exclusively distance learning via the Internet. The contents of the three modules of the first study semester were transformed into electronic documents and were offered to students online by means of the Virtual Medical Campus Graz. This is a comprehensive, Web-based learning platform which had been developed previously at the Medical University of Graz 4–6 to support teaching and learning. In January 2006, all preliminarily accepted students had to pass a two-day selection procedure. On day 1, there was a written assessment in multiple-choice (MC) format based on the students' knowledge of the three modules. On day 2, the students took an additional MC test further assessing their knowledge of biology, chemistry, physics, and mathematics on the secondary school level. The available admission openings were awarded to the 107 applicants ranking highest after both assessments. These applicants then were fully admitted to further study. All other applicants were excluded from continuing their study.

 

두 번째 단계는 2006-2007학년도에 도입된 것으로서, 지금까지도 계속되고 있는데, Graz의과대학은 지원자의 수행능력을 기반으로 한 선발 과정을 치른다. 이 시험은 앞에서 제2일에 시행한 시험을 기반으로 만들어졌으며, 주로 고등학교 수준의 생물, 화학, 물리, 수학 시험을 보고, 과학교과에 대한 지원자의 이해능력을 평가한다. 자연과학 부분에 초점을 둔 이러한 시험을 도입한 주 근거는 오스트리아 고등학교 교육과정이 워낙 다양해서 의과대학에 입학한 많은 학생이 고전한다는 오래된 관찰 결과에 기반한 것이다. 

The second process was implemented for academic year 2006–2007, and it continues today. The Medical University of Graz employs a selection procedure based on an applicant's performance on a required MC test prior to admission. This test was built on the basis of the test used on day 2 of the previous admission test. It is based mainly on secondary-school-level knowledge of biology, chemistry, physics, and mathematics and further includes assessment of the applicant's comprehension of scientific texts. A major rationale for using an admission test focusing mainly on the natural sciences was the long-standing observation that, because of strong heterogeneities in Austrian secondary school education, many medical students faced massive difficulties—and hence, the largest risk to fail and to drop out of study—during the initial study semesters, which are dominated by these scientific disciplines.

경험이 풍부한 대학 교수가 시험을 출제하며, 시험은 매년 7월 치러지고 성적이 좋은 지원자만이 의과대학에 입학할 수 있다. 현재, Graz에서 사용하고 있는 입학 시험은 일부 독일 의과대학에서 사용하는 입학 과정과 유사하며, 이들 대학과 향후 더 협력할 계획을 가지고 있다.

Experienced university faculty produce the test items. The admission test takes place in July each year during the holiday season of schools and universities. Those applicants who rank best on the admission test are admitted to study. Presently, the admission test is used only at the Medical University of Graz, but there are similar admission procedures at some German medical faculties (e.g., University Medical Center Hamburg–Eppendorf), and we are considering cooperating more closely with these faculties in the future.

 

Studying the effects

 

우리가 기대하는 것은 학생들의 수학기간(6년 교육과정임에도 9년간 공부하는)의 단축, 그리고 탈락률(50%이상)이 감소하는 두 가지 이다.

In summary, starting with academic year 2005–2006, a fundamental change in Austria's admission practice for medical studies caused leaders at the Medical University of Graz to implement sweeping reforms to their own admissions practices. Not only was the threat of becoming overwhelmed by German students removed, the university was for the first time able to adjust the number of fresh medical students according to the capacities available. Two major research hypotheses—and indeed hopes—accompanied the introduction of selective admission procedures: We expected that students' overlong study times (approximately nine years instead of six years as scheduled) as well as the absurdly high study dropout rates (50% or more) would be efficiently reduced.

We addressed the first of these research questions, namely, the effect of the change in admission practice on study progress rates, in a previous analysis.7 In the present investigation, we investigate the second important question mentioned above: Is there a measurable effect on dropout rate of the change in admission practice from open admission to active selection of students? How large is the putative effect? Do demographic variables such as students' nationality, age, and sex significantly modulate the putative effect?

Method

 

Participants

We included in the study all new students routinely enrolled in the new diploma human medicine program during the academic years 2002–2003 to 2008–2009. We excluded from the investigation students being admitted by any other route (e.g., students with prior credits from medical studies at the Medical University of Graz or elsewhere).

총 2860명의 학생

In total, we included 2,860 students for statistical analyses. Of these, 1,971 (68.9%) were openly admitted during academic years 2002–2003 to 2004–2005; 889 (31.1%) were admitted after passing an admission procedure during years 2005–2006 to 2008–2009.

코호트별로 observation period가 다름

Data on study progress were accumulated from academic year 2002–2003 until the end of the winter semester in academic year 2009–2010 (February 28, 2010). Thus, the observation period varies among cohorts from the investigated academic years. Whereas students who were enrolled in 2002 and 2003 were observed for more than six years and thus were able to reach graduation during the observation time, the observation period for students who were enrolled in 2004 and later was shorter than the scheduled six years of the curriculum.

남성 여성, 연령. 연령은 3분위수를 이용하여 20.89세를 기준으로 이분화함. 1~3분위는 매우 숫자가 가까웠음. 그래서 나머지를 '나이든' 그룹으로 묶음.

The study included 1,230 men (43.0%) and 1,630 (57.0%) women. Age range was from 17.51 to 50.03 years (median: 19.69 years; first quartile: 18.92 years; third quartile: 20.89 years). As in our previous investigation,7 for subsequent analysis we arbitrarily dichotomized the variable “age at study entry” at the third quartile of 20.89 years. There was no other motivation for the dichotomization just at this age other than to compare younger and older participants; because the first, second, and third quartile are very close, the third was taken to ensure a reasonable number of participants in the “older” group. Finally, 2,481 of the students (86.7%) were Austrians, 226 (7.9%) were Germans, and 153 (5.4%) came from other nations.

학생을 선별할 수 없도록 데이터를 수집하였음. 

We gathered the deidentified data from information that is routinely collected about medical students' admission, dropout, and graduation dates and examination history, as required by the Austrian Federal Ministry of Science and Research. Because the data were anonymous and no data beyond those required by law were collected for this study, the Medical University of Graz's ethical approval committee did not require approval for this study.

 

통계

Statistical methods

탈락하는 학생에 대해서 학생이 탈락하고 말고 뿐만 아니라, 어느 단계에서 탈락하느냐도 중요함. 

Phenomena such as students prematurely dropping out of a program are intrinsically time-dependent: Besides the question of whether or not a student drops out, it also matters when in the course of study this event occurs. Proper analysis of dropout, therefore, must include the time elapsing between a defined starting event (in our analysis, this is the date of enrollment) and the terminating event under consideration (the date of dropout) as a central variable. 

ANOVA나 회귀분석 같은 방법은 적절하지 않음. 학생마다 모두 학습이 달라서 모든 학생이 탈락하거나 모든 학생이 졸업할 때까지 기다릴 수 없음. 

Application of ordinary statistical methods, such as analyses of variance or regression techniques, frequently are not suitable in investigations of this type. First, study progress of participants may vary considerably, and one might be interested in drawing sound conclusions without waiting until all participants have either dropped out or reached graduation. Under reasonable circumstances, only a fraction of participants will experience the terminating event “dropout” within a given observation time, and—at least in principle—other participants may get lost from the observation for reasons other than dropout (e.g., graduation). This latter phenomenon is called censoring. Participants experiencing the defined termination event during the observation period carry full information for statistical analysis (“they have experienced the terminating event after a well-defined time interval”). Participants who do not drop out of study during the observation period nevertheless contribute important information, at least for the time period under observation (“they have not experienced the terminating event during a well-defined time interval”) but not thereafter.

이러한 경우에 의학에서는 생존분석을 하게 됨. 입학 전형 또는 인구학적 특성에 따라서 탈락율 차이를 분석함.

In medicine, we meet situations of this type very commonly in survival studies. In these cases, the starting point very frequently is the date of diagnosis of, for example, a malignant tumor, and the terminating event might be the date of detection of tumor recurrence or metastasis or even death. Consequently, we analyzed the effects of open admission versus active admission procedure as well as of some selected demographic variables on dropout rates by statistical methods from the field of survival analysis.8

 

Here, we distinguish between nonparametric, semiparametric, and parametric methods. The product-limit approach by Kaplan and Meier 9 does not make any assumption concerning the underlying hazard function (“baseline hazard”) for the terminating event under scrutiny but estimates the cumulative probabilities of “survival” (for our purpose, this corresponds to “retention in study”) merely from the empirical data at hand. Thus, it is a nonparametric method. The proportional hazards method by Cox 10 also does not make any assumption about the baseline hazard; the effect of covariates, however, is modeled by a parameterized analytic expression. The model parameters are estimated from the data and allow, in a multivariate fashion, quantification of the relative predictive strengths of the variables included with regard to the terminating event. The Cox method is thus a semiempiric one. Finally, there are a host of parametric models which provide explicit mathematical models for the baseline hazard as well as covariate effects. These models assume one of several possible distribution models for the baseline hazard (e.g., exponential distribution, Weibull distribution, Gompertz distribution, and others) with adjustable parameters. If appropriate, such models allow the estimation of cumulative probabilities as a function of time by means of an explicit analytic expression.

 

We used the nonparametric product limit technique by Kaplan and Meier to compute the cumulative probabilities for retention in the course of study for student categories defined on the basis of several variables: mode of admission (open admission versus selection), sex, age, and nationality. Such cumulative probabilities are usually represented graphically by typical step functions decreasing from 1.0 to smaller values, as observation time progresses. We tested differences of cumulative retention probabilities among different categories by the generalized likelihood ratio method (Breslow [chi]2 statistic).11 To visualize the time-dependent risk of experiencing dropout for students in defined categories, we computed smoothed hazard functions for dropout according to Muller and Wang.12 These smoothed hazard functions give the instantaneous probabilities that a participant will experience a terminating event at time “t.” Roughly, they represent the negative first derivative with respect to time of the cumulative retention probabilities. We employed the semiparametric proportional hazards model by Cox in order to study the combined effects of potential predictor variables in a multivariate manner and to identify the relative strength of each individual predictor variable in the context of all other variables.

All statistical evaluations, including basic statistics for comparison of mean values and frequencies among different groups of students, were done using commercially available software (Stata Statistical Software: Release 11; StataCorp, 2009, College Station, Texas).

Results

Cumulative probability of dropout was significantly reduced in students selected by active admission procedure versus those admitted openly (P < .0001). Relative hazard ratio of selected versus openly admitted students was only 0.145 (95% CI, 0.106–0.198). 

Among openly admitted students, but not for selected ones, the cumulative probabilities for dropout were higher for females (P < .0001) and for older students (P < .0001). Generally, dropout hazard is highest during the second year of study.

Conclusions

The introduction of admission testing significantly decreased the cumulative probability for dropout. In openly admitted students a significantly higher risk for dropout was found in female students and in older students, whereas no such effects can be detected after admission testing. Future research should focus on the sex dependence, with the aim of improving success rates among female applicants on the admission tests

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Acad Med. 2011 Aug;86(8):1040-8. doi: 10.1097/ACM.0b013e3182223a1b.

Dropout rates in medical students at one school before and after the installation of admission tests in Austria.

Reibnegger G1, Caluba HC, Ithaler D, Manhal S, Neges HM, Smolle J.

Author information

Abstract

PURPOSE:

Admission to medical studies in Austria since academic year 2005-2006 has been regulated by admission tests. At the Medical University of Graz, an admission test focusing on secondary-school-level knowledge in natural sciences has been used for this purpose. The impact of this important change on dropout rates of female versus male students and older versus younger students is reported.

METHOD:

All 2,860 students admitted to the human medicine diploma program at the Medical University of Graz from academic years 2002-2003 to 2008-2009 were included. Nonparametric and semiparametric survival analysis techniques were employed to compare cumulative probability of dropout between demographic groups.

RESULTS:

Cumulative probability of dropout was significantly reduced in students selected by active admission procedure versus those admitted openly (P < .0001). Relative hazard ratio of selected versus openly admitted students was only 0.145 (95% CI, 0.106-0.198). Among openly admitted students, but not for selected ones, the cumulative probabilities for dropout were higher for females (P < .0001) and for older students (P < .0001). Generally, dropout hazard is highest during the second year of study.

CONCLUSIONS:

The introduction of admission testing significantly decreased the cumulative probability for dropout. In openly admitted students a significantly higher risk for dropout was found in female students and in older students, whereas no such effects can be detected after admission testing. Future research should focus on the sex dependence, with the aim of improving success rates among female applicants on the admission tests.

PMID:

 

21694561

 

[PubMed - indexed for MEDLINE]