두뇌유출(Brain drain) 감소를 위한 프로그램 : FAIMER education programs

Slowing the brain drain: FAIMER education programs

WILLIAM P. BURDICK, PAGE S. MORAHAN & JOHN J. NORCINI 

Foundation for Advancement of International Medical Education and Research, Philadelphia, USA

Introduction

- 개발도상국에서 의사인력의 유출(migration)은 세계 곳곳에서 심각한 의료인력부족을 낳고 있음.

- Migration의 충격 : 교육받은 시민의 손실, 의료공금자의 손실, BME, GME에서 연구역량과 교사의 손실

- 두뇌유출을 늦추는 것은 복잡한 노력이 필요하나 다양한 노력을 통해서 줄여나갈 수 있다.

- 양질의 미국 의학교육은 GME단계에서 많은 인력을 끌어당기고 있다. 그리고 이들은 수련을 마친 후에도 미국에 남는 경우가 많다.

- FAIMER는 ECFMG(Educational Commission for Foreign Medical Graduates)의 supporting corporation으로서 지난 5년간 교수개발 프로그램을 만들어서 해외 의학교육을 강화시키고, 진로발전을 도움으로써 의료인력이 부족한 국가의 공급을 늘리는데 기여하고자 했다.

Migration of physicians from developing countries has created serious shortages of medical manpower in many parts of the world (Marchal & Kegels, 2003; Mullan, 2005). The impact of migration on donor countries includes loss of educated citizens, healthcare service providers, research capacity and teachers at the undergraduate and postgraduate medical level (Aluwihare, 2005). Slowing the brain drain is a complex endeavor but developing skills, creating professional networks and enhancing opportunities for career advancement of physicians may be an important element in diminishing out-migration. The attraction of high-quality US medical education, and especially graduate medical education, has drawn thousands of foreign physicians to postgraduate training programs in the US (Whelan, 2002). After training is complete, many of these individuals are granted visa waivers by federal or state agencies and stay to practice medicine in the US. The Foundation for Advancement of International Medical Education and Research (FAIMER), a supporting corporation of the Educational Commission for Foreign Medical Graduates, has created faculty development programs over the past five years to strengthen medical education and career advancement for medical educators overseas, thus supporting the expanded production of physicians in those countries where there is an undersupply.

- FAIMER의 교육 프로그램은 세 부분으로 이루어져 있다. 

FAIMER's education program has three components. 

• The FAIMER Institute, started in 2001, awards a two-year fellowship focused on educational leadership and methodology. It consists of two brief residential experiences in the US integrated with distance learning (Norcini et al., 2005). 
• The International Fellowships in Medical Education (IFME) program is an advanced-level fellowship that funds selected graduates of the Institute to obtain a master's in medical education at academic institutions around the world. 
• Most recently, FAIMER has begun to develop regional institutes in other parts of the world based on the principles embedded in the original FAIMER Institute. The purpose of this paper is to present the goals of the program, describe the components in detail, present data concerning their efficacy and outline plans for the future.

Goal

- FAIMER프로그램의 최종 목적은 개발도상국에 지속가능한 의학교육Discipline을 구축하여 해당 국가의 의학교육을 가능하게 하는 것이다. 

- 강력한 의학교육 시스템의 효과는 몇 가지로 나눠볼 수 있다. (BME, GME, CPD)

The overarching goal of the FAIMER education program is to strengthen medical education and help build a sustainable discipline of medical education in developing countries. The effects of a stronger medical education system are several. 

• At the undergraduate medical education level, there is the possibility that it may attract higher quality students to the field and improve their rate of retention; increased attraction and retention has been shown in US medical schools (Milbank, 2005). 
• The development of local high-quality postgraduate education will enhance opportunities for completing medical training in their home country. 
• Strong systems for undergraduate and postgraduate education are likely to create an impetus for continuous professional development, further increasing the attractiveness of practicing medicine in their home country. 

- 개발도상국에게 의학교육 원칙(discipline of medical education)을 확립하게 하는 전략으로는 다음과 같은 것이 있으며, 최종적인 효과는 양질의 의사를 양성하여 그 지역 인구의 건강을 증진하는 것이다.

Strategies for facilitating development of the discipline of medical education in developing countries include: 

• creating a critical mass of educators and supporting the interaction of these individuals, 
• providing access to educational resources, 
• developing leaders in medical education, and 
• encouraging and facilitating scholarly work in this domain. 

The net effect of these efforts should be to increase the production of high-quality physicians likely to serve populations in their country of training, thereby improving the health of the population.

- FAIMER의 교육 프로그램은 남아시아, 아프리카, 남아메리카를 주요 대상으로 하며, 이들 대상이 선정된 주요 근거는 다음과 같다. 그러나 이들 지역 외 지역에서도 매년 지원자가 있다.

FAIMER's educational programs currently focus on South Asia, Africa and South America. These regions were chosen based on 

• (1) need, 
• (2) stability and accessibility, 
• (3) the capacity to use and sustain the resources FAIMER contributes and 
• (4) the number of former Fellows in the area. 

Applications from other regions, however, are accepted each year.

FAIMER education programs

FAIMER Institute

FAIMER Institute는 gateway 프로그램으로서, 여기에 지원하는 사람들은 영어를 유창하게 할 수 있어야 하며, 지원 시점, 합격 시점, Fellowship진행 과정 동안 본국에서 거주하며 근무중이어야 한다. 이 지원의 핵심 요소는 교육과정혁신프로젝트(Curriculum innovation project)이며, 지원자가 이 프로젝트를 작성하면 단/장기 적으로 평가받게 된다.

The FAIMER Institute is the gateway program for education activities. Applicants for the Institute, who are required to speak English at a high level of proficiency, must reside and work in their home countries at the time of application, acceptance and duration of the Fellowship award. Central to the application is a curriculum innovation project in which the applicant describes the purpose of the innovation, how the change would be implemented, and how the success of the project would be evaluated in the short and long term. The curriculum innovation project becomes the vehicle for learning about concepts of leadership and education methodology.

2년짜리 프로그램인 FAIMER Institute는 매년 16명의 참가자가 있으며 4세션으로 진행된다. 두 세션은 미국에 머물며 진행되고 두 세션은 원거리 학습을 한다.

The two-year program, with 16 participants each year, includes four sessions—two residential in the United States and two distance learning. 

세션1 : 첫 번째 세션은 세 가지 주제로 구성되어 있다.

During Session 1, a three-week residential component, there are three curriculum strands. 

Fellows acquire basic skills in medical education, including large-group teaching, problem-based learning, student assessment and program evaluation. 

Fellows also gain skills in leadership and management. 

These include: assessment and understanding of their own leadership style and how to use that insight when working with others, project management tools, managing change processes, handling conflict, understanding group dynamics, the nature of high performance teams, and appreciative leadership (Dorsey, 2000; Bushe, 2001; Burns, 2003). 

The third strand encompasses building a strong community of practice (Wenger et al., 2002). Fellows are involved in a variety of methods to create community, including sharing their professional ‘stories’ (Wheatley, 2005) learning about the concept of social capital and how communities of practice are built and maintained (Baker, 2000; Abrahamson, 2004) and experiencing the role of co-mentoring. To make learning concrete and meaningful, the Fellow's project is the focus of special attention throughout the session. Individual, small-group and large-group discussions are used, as is feedback from peers and experts. The goal is for the Fellows to refine their projects and be ready to implement them on their return home.

세션2 : 첫 번째 미국내 세션이 끝나면, 연수생들은 본국으로 돌아가서 프로젝트를 수행하면서 두 번째 세션에 참가하는데 이 때는 인터넷을 활용한 멘토링과 원거리 학습 프로그램이 이용된다.

After the first residential session, the Fellows return home to conduct their projects and participate in Session 2, a mentoring and distance-learning program on the Internet (Mentoring and Learning Web, or ML-Web). During Session 2, they are co-mentored by a second-year fellow and a Global Faculty Adviser (selected from previous graduates). 

세션3 : 1년차의 마지막 2주를 다시 미국으로 돌아와서 advanced 과정을 밟고 co-mentoring을 진행할 새로운 1년차 연수생과 연결된다.

The Fellows return to the US for approximately two weeks at the end of the first year for workshops on advanced leadership, management and education issues, and to connect with the first year Fellows they will be co-mentoring (Session 3). 

세션4 : 세션2의 ML-Web을 다시 활용하게 되며 학술업적을 이뤄야 한다.

In Session 4, second-year Fellows participate in the ML-Web, developing required scholarly output and co-mentoring a first-year Fellow.

FAIMER Regional Institutes

FAIMER Institute의 참가자들이 residential session 기간동안에 미국에 와야 하는 것과 달리 FAIMER RI는 개발도상국의 의과대학에서 진행되며 주변 지역에서 참가자들이 온다. 

While participants in the FAIMER Institute come to the US for residential sessions, the FAIMER Regional Institutes are conducted at medical schools in developing countries for participants from the surrounding area, using principles embedded in the FAIMER Institute. 

지난 3년간 다양한 지역 프로그램(local initiative)가 있었다. 하나는 2005년 7월에 시작했고, 다른 하나는 2006년 1월에 시작하였으며, 나머지 두 개는 현재 개발중이다.

A variety of local initiatives have been conducted over the past three years. One Regional Institute started in July 2005, another began in January 2006, and two others are currently in development. The experimental and iterative growth process involves: 

(1) full respectful partnership with the local organizers, 

(2) co-creation of a curriculum that fits the local context and needs, 

(3) local capacity regarding resources for all logistical issues, 

(4) commitment by local organizer to facilitate FAIMER networking in the region through participation of FAIMER Institute graduates as faculty, and 

(5) dual learning by FAIMER and the local organizing entity that informs future efforts (Plsek, 2001).

RI는 FAIMER Institute 교재를 활용하며, 미국에서 FAIMER Institute를 성공적으로 이수한 해당 지역의 교수의 리더십에 따라 진행된다. 교수진(faculty member)은 주로 그 지역에서 오며, 여기에 추가로 일부 해외 교수진이 추가된다. 첫 몇 년간은 자금을 지원해주며 그 이후는 해당 지역 참가자와 의과대학이 비용을 부담할 것으로 기대한다.

Regional institutes are created using FAIMER Institute materials, with leadership by local faculty who have completed and excelled in the Institute in the US. Faculty members are predominantly from the region, with addition of some international faculty. Funding is provided for the first several years of operation, with the expectation that local participants and their medical schools will provide ongoing funding in subsequent years.

Other regional initiatives have ranged from co-creation of medical education skill-building workshops for clinical skills assessment to co-creation of medical educator leadership and project-management workshops. These involved partnership with FAIMER faculty for curriculum design, and travel of FAIMER faculty to participate in the workshops. FAIMER faculty have also facilitated individual and collaborative medical education scholarship development through on-site consultation.

The first regional institute was started in July 2005 in Mumbai, India. 

Seth Gordhandas Sunderdas Medical College (GSMC) was selected because of the presence of an existing faculty development program, the involvement of an Institute graduate, the support of the medical school leadership, and the institution's outstanding reputation. The GSMC-FAIMER Regional Institute is being created from the existing faculty development program, which was approximately three days in duration. The first iteration of the regional institute transformed it into a two-year program with two five-day residential sessions, a curriculum innovation project and a distance learning component. Because of geographic proximity, several brief interim meetings, as well as on-site consultations, have been possible. The residential components will be lengthened gradually until they are each about 10 days in duration.

Education methodology workshop topics during Session 1 of the GSMC-FAIMER Regional Institute in 2006 have included the teaching and learning process, group dynamics, writing objectives, small- and large-group teaching, use of audiovisual tools and student assessment, as well as multiple-choice question formulation. Leadership and management topics have included team building, networking and change management. Significant time has been allocated to project management and educational project design, especially as related to participants’ curriculum innovation projects.

The Regional Institute in Ludhiana, India began January, 2006 at Christian Medical College—Ludhiana (CMCL). 

CMCL-FAIMER Regional Institute is under the leadership of a former Institute fellow, and includes participants from the Punjab, but also from the New Delhi, Mumbai and Bangalore areas. Faculty are from the home institution, the South Asia region, as well as from other international institutions. Development discussions are underway for additional regional institutes in Brazil and South Africa, as well as other parts of South Asia and Africa.

International Fellowships in Medical Education

승진에 필요한 연구와 학문을 위해서 뿐만 아니라 더 깊은 지식을 위해서도 고급학위(advanced degree)가 중요하다. 그러나 교육 관련 고급학위(advanced degree)가 없는 경우에 실험 또는 역학 연구 학위를 받아야 하고, 이로 인해 애초에 교육에 관심이 있었던 사람들이 멀어지게 된다.

Advanced degrees are useful for developing in-depth knowledge as well as skills in research and scholarship, which are essential for promoting a cadre of professionals in any field. In medical schools around the world, an advanced degree beyond the initial clinical medicine degree is often a prerequisite for faculty promotion. If advanced degrees in education are not available, aspiring faculty seeking promotion must pursue academic work in other areas such as bench research or epidemiology, distracting them from a possible career in medical education.

FAIMER Institute 와 Regional Institute의 졸업생은 IFME에 지원할 수 있으며, 세계 어디에서든 입학하여 원격교육을 통해 석사학위를 받을 수 있다. 연수생들은 advanced standing을 받을 수 있으며, 학위를 받을 때 까지는 3년이 걸린다. 모든 프로그램은 약간의 residential component가 있다.

Institute and regional institute graduates are eligible to apply for an International Fellowship in Medical Education award, which supports matriculation at an approved master's in education program anywhere in the world using a distance-learning format. Fellows receive slightly advanced standing for their work at the Institute, and they have three years to complete the degree. All programs have a modest residential component so that participants can create better connections with their fellow students and faculty.

Evaluation of the FAIMER education programs

FAIMER 교육 프로그램의 평가는 프로그램 평가의 logic model과 Kirkpatrick의 모델을 이용하여 정량적, 정성적 접근을 같이 하였다. 즉각적 반응은 각 워크숍 직후에 설문을 통해 평가하였으며, 지식과 태도의 변화는 'retrospective pre-methodology'를 사용하엿다. 행동의 변화는 세션3 이후 주기적으로 심층 면접을 시행하여 평가하였다. 

Evaluation of the FAIMER education programs combines qualitative and quantitative approaches, and is organized using the logic model of program evaluation (WF Kellogg) and Kirkpatrick's levels of impact (Kirkpatrick, 1994). Immediate reaction to sessions is assessed through detailed questions concerning the quality of each workshop. Change in knowledge and attitudes is assessed using ‘retrospective pre-methodology’ (Skeff, 1992). Change in behavior, as well as knowledge and attitudes, is assessed through in-depth interviews at the end of Session 3 and periodically after the conclusion of the program. Data are collected and analysed by an independent team from the University of New Mexico Office of Program Evaluation, Assessment and Research.

retrospective pre-data의 분석으로부터 모든 여덟 개 의학교육 분야에 대해서 통계적으로 유의미한 효과가 있었음을 확인하였고, 여섯 개의 리더십과 경영 분야에서 통계적으로 유의미한 효과가 있음을 확인하였다. 

Analysis of the retrospective pre-data from the first three classes has shown large, statistically significant effects in all eight areas of medical education (international medical education, educational methods, assessment of student performance, educational program evaluation, educational projects, international medical education day, distance education, qualitative evaluation methods) and all six areas of leadership and management (change theory and management, personal professional development, project management, advanced leadership, whole systems models to sustain change, electronic learning and management). These indicate the impact on Fellows’ perceptions of the importance of the areas, as well as on their self-ratings of growth in knowledge, skills and attitudes before and after the Institute.

의학교육과 리더십의 지식과 술기 향상 외에도, Institute의 주요 목적 중 하나는 개발도상국에서 의학교육의 교수개발이 중요한 원칙(recognized discipline)이 되도록 하는 것이었다. 

In addition to increasing knowledge and skills in medical education and educational leadership, a major goal of the Institute is to facilitate development of medical education as a recognized discipline in developing countries. 

Fellows are developing both individual and collaborative scholarship. In addition to an almost 100% rate of return and retention for Institute Fellows (45/46 from the first four Institute classes), they are growing professionally at their institutions. 

• Of the 45 Fellows who have completed the program, 
• 16 have made a total of 31 presentations at international meetings; 
• six have produced 15 peer-reviewed publications; and 
• 13 grants and 15 awards in medical education have been obtained. 
• Two Fellows have obtained an advanced education degree, and 
• 14 have received an academic or administrative promotion to associate or full professor, department chair, sub-dean or dean.

Institute의 또 다른 주요 목표는 지역 수준, 국제적 수준에서 의학교육자들의 네트워크를 구축하는 것이었다.

Another major goal of the Institute is to foster development of close regional and international networks of medical educators—a cohesive international community of medical education practice. Analysis of their networks prior to the Institute has shown that the classes of 2001 to 2004 had professional networks that were initially small in number, dense (most members of their networks knew each other) and near by geographically. After the Institute, the Fellows’ professional networks had become larger, less dense and more diverse geographically.

Future plans, implications for slowing the brain drain

Our experience emphasizes that development of an international program with high-quality regional medical educational leadership institutes must take place slowly and deliberately, and be adaptable to emerging opportunities (Baker, 2000; Buchanan & Booker, 2004). Starting with an existing faculty development program, the lead time for development of a new regional institute is approximately 1–2 years. Evaluation data from the first regional institutes will need to be collected for several years before meaningful inferences can be made and used for improved development, implementation, model distribution and evaluation of other regional institutes. We anticipate that several more regional institutes and initiatives may be developed each year.

As regional institutes become stronger, we anticipate a shift in the emphasis of the FAIMER Institute. The program in the US may become more of a faculty-development leadership institute, emphasizing the skills necessary to design and manage faculty development programs, and regional institutes in particular. The central program may increasingly facilitate collaborative scholarly endeavors with Fellows around the world, using the extensive FAIMER research expertise for research design, data collection and analysis.

The field of medical education in developing countries will mature as a critical mass of skilled, internationally recognized medical educators evolves through initiatives such as FAIMER's faculty-development opportunities and facilitation of scholarly output. Increased feasibility and attractiveness of developing as a medical educator in one's home country may help slow the medical faculty brain drain.

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Med Teach. 2006 Nov;28(7):631-4.

Slowing the brain drain: FAIMER education programs.

Burdick WP1, Morahan PS, Norcini JJ.

Author information

Abstract

Migration of physicians has produced serious shortages in many developing countries. The Foundation for Advancement of International Medical Education and Research (FAIMER) is attempting to show this international brain drain through creation of faculty development programs for medical school faculty from developing countries in order to strengthen medical education and help build a sustainable discipline of medical education. The goals of these programs are to allow Fellows to acquire basic skills in medical education, skills in leadership and management, and build a strong community of practice. Acquisition of these skills will improve medical education in their home country, stimulate growth of the field of medical education, and improve opportunities for professional advancement. Three programs currently exist: the FAIMER Institute, a two year fellowship with residential and distance learning components; International Fellowships in Medical Education, which funds selected Institute alumni to obtain masters degrees in medical education; and FAIMER regional institutes, which use the principles and structure embedded in the FAIMER Institute to build faculty development programs overseas. Evaluation of FAIMER programs indicates approximately one-third of Fellows have been promoted, and that a community of medical educators is being created in many developing countries which may promote retention of these physicians.

PMID:

 

17594555

 

[PubMed - indexed for MEDLINE]