전 세계 의과대학 개관(overview)

An overview of the world’s medical schools

JOHN BOULET1, CAROLE BEDE2, DANETTE MCKINLEY1 & JOHN NORCINI1

1FAIMER, Philadelphia, USA, 2ECFMG, Credentials, Philadelphia, USA

배경

Background

글로벌 보건의료인력 차원에서 적절한 훈련을 제공하는 것은 매우 중요하나, 최근의 환경을 보면 보건의료시스템에 대한 수요가 많아지고, 의사들은 지역과 지역을, 국가와 국간을 자유롭게 오갈 수 있다. 즉, 의학 수련에 대한 선택 옵션이 많아졌는데, 그 결과로 수련 기관의 분포와 질에 대한 정보를 수집하는 것이 보건의료인력에 대한 계획 수립 차원에서 매우 중요한 일이 되었다. 의학교육은 확실히 진로 선택 패턴 및 진료 패턴에 영향을 주고 있고, 그 결과로 전 인구적 건강에도 영향을 미치는데 이는 특히 덜 개발된 지역에서 심각하다.

Providing training that will ensure an adequate global healthcare workforce is essential. However, in today's global environment, where there are increasing demands on healthcare systems, physicians are free to move from locale to locale or even from country to country. More important, for many of these individuals, there have been, and continue to be, numerous options as to where the medical training can take place, including institutions located outside their home countries. As a result, obtaining information on the distribution and quality of training institutions is critical to health workforce planning (World Health Organization 2006). Medical education will certainly affect practice patterns and influence career choices, thereby having some distributed net effect on population health, especially in underdeveloped regions or those countries where relatively few practitioners are being trained. Having information about medical schools, including where they are located, and how this has changed over time, is paramount.

일부 의학교육의 global pipeline을 다룬 연구들이 있지만, 의과대학의 수가 빠르게 증가하면서 '현재의' '정확한' 정보를 수집하는 일이 더욱 중요해졌다. 의사 교육에 대한 global capacity를 제대로 이해하려면 데이터 수집이 향상되어야 하고, 또한 무엇보다 중요한 것은 그 정보가 공유되어야 한다.

Although some research has been conducted to track the global pipeline of medical education, the rapid growth in the number of medical schools demands that any information collected is both current and accurate. In 2002, Eckhert described the distribution and physician output of the world's medical schools (Eckhert 2002). She concluded that in areas of predicted substantial population growth, the production of physicians is not sufficient to overcome low physician–population ratios. Moreover, due to incomplete data, tracking the number and distribution of medical schools and their student capacity was found to be an arduous and complex task. Therefore, to better understand the global capacity to educate physicians, the available data sources need to be improved and, most important, shared.

의과대학에 대한 이러한 정보원은 몇 가지가 있고 어떤 것은 다른 것보다 더 정확하거나, 더 현재의 상태를 잘 반영하는 것도 있다. 그러나 현재 이러한 자료들은 모두 한계점이 많다.

There are a number of sources of information concerning medical schools, some more accurate and current than others. 

• Historically, the World Health Organization (WHO) published and maintained the World Directory of Medical Schools (World Health Organization 2000). This comprehensive directory, last published in 2000, provides descriptions of medical education programs and lists of training institutions, by country or area. Although the WHO website has additional data for some schools up to the 2004 calendar year (World Health Organization 2004), much of the information presented reflects the academic situation several years prior to that. 

• The Institute for International Medical Education (IIME) maintains a database of medical schools, including links to most of the medical school home web pages. As of December 2005, there were 1848 schools listed in 166 countries (Institute for International Medical Education 2005). Much of the information in the database was generated from a medical school survey conducted in 2000. Although this survey solicits contact information, admission requirements, enrollment data, assessment methodology and curriculum content, relatively few medical schools appear to have provided these detailed data. Moreover, this information is not currently available on the public domain website. Similar to the WHO Directory, a listing in the IIME database does not serve as a grant of international recognition of the medical school.

• The Association of American Medical Colleges (AAMC) maintains a listing of all US and Canadian Medical Schools, including links to each school's website. In addition to this listing, the AAMC provides a Curriculum Directory that contains detailed information on courses offered, clerkships, promotion and graduation requirements, etc., by medical school (Association of American Medical Colleges 2005a; Association of American Medical Colleges 2005b). 

• Similar to the AAMC, the American Association of Colleges of Osteopathic Medicine (AACOM) provides comparative medical school information for all osteopathic medical colleges in the US. 

• For medical schools worldwide, the International Federation of Medical Students’ Associations (IFMSA) created a curriculum database that includes country-based data on medical schools, including medical training period, number of graduates, residency requirements, and the existence of a national accreditation process (International Federation of Medical Students' Associations 2005). 

• To date, however, relatively few countries are listed. Similar to the US and Canada, for some countries (e.g. India), the responsible recognizing or accrediting bodies provide detailed information on the management and characteristics of the medical colleges under their jurisdictions (Medical Council of India 2005). 

• Various other organizations, both public and private, also provide partial listings of the world's medical schools and, in some instances, more comprehensive data on the qualities of the training programs. Unfortunately, much of this more relevant and detailed information is only available on individual medical school websites.

FAIMER는 IMED를 보유하고 있다. IMED는 '최신의' '정확한' '지속적으로 업테이트되는' 데이터베이스라 할 수 있다.

The Foundation for Advancement of International Medical Education and Research (FAIMER) maintains the International Medical Education Directory (IMED) (Foundation for Advancement of International Medical Education and Research 2005). 

IMED is a free, web-based resource of the world's medical schools. 

The directory provides an accurate and up-to-date resource containing information on medical schools that are recognized by the appropriate government agencies in the countries where the schools are located.1 

Unlike the inclusion criteria employed by some of the other organizations who maintain medical school resources, with the notable exception of the WHO,2 a medical school is only listed in IMED after FAIMER receives confirmation from the Ministry of Health or other appropriate agency that the school is recognized. 

In addition, medical students who wish to pursue graduate medical education in the US must have their medical school listed in IMED. This is one of several requirements that are necessary for certification by the Educational Commission for Foreign Medical Graduates (ECFMG®). As a result, IMED must remain current, and is continuously updated.

Although there may be numerous schools that are not recognized within their host country, thus precluding their listing in IMED, the International Medical Education Directory does provide a starting point for describing the world's medical schools and colleges. The information available in IMED includes the school's current name and university affiliation, previous names and contact information. In addition, basic demographic information is readily accessible.

결과

Results

235개 국가 중에서 169개 국가는 하나 이상의 의과대학을 보유하고 있으며, Top20국가가 Table 1에 있다. 2006년의 IMED목록에 따르면 인도가 가장 의과대학이 많고, 그 다음으로 미국이 따르고 있다. 전 세계 의과대학의 1/3이 다섯 개 국가에 있으며, 절반의 의과대학은 10개 국가에 있다.

Of the 235 countries and dependencies in the world, 169 have at least one medical school. The countries with the most medical schools are presented in Table 1. Based on IMED listings in April 2006, India has the most recognized medical schools (n = 219), followed by the United States (n = 147, allopathic and osteopathic). Over one-third of all the world's medical schools are located in one of five countries; nearly half are located in 10 nations.

지역별 의과대학 분포는 Table2에 정리되어 있다. 평균적으로 330만명당 한 개의 의과대학이 있다.

The number of medical schools by continent and region is presented in Table 2. The 2004 continent and region populations, medical school densities, number of physicians and physician densities are also provided. While there are some associations amongst the number of medical schools, the population and the number of physicians, there is substantial variation from region to region. Based on the IMED total of 1935 operating medical schools, there is, on average, one medical school for every 3.3 million persons in the world. 

아시아에는 가장 많은 인구와 가장 많은 의과대학이 있지만 60%의 인구가 있는 것에 반해 44%의 의과대학만이 있다. 의사 밀도도 낮다. 

Asia, with the largest population (approximately 3.9 billion people) has the most medical schools (n = 860). However, while over 60% of the world's population resides in Asia, only 44% of the medical schools are located there. Moreover, physician density is low, with less than one physician, on average, per 1000 population. 

16%의 의과대학이 북미에 있으나 8%의 인구만이 북미에 산다. 

In contrast, nearly 16% of the world's medical schools are located in North America; only 8% of the world's population resides there. The relatively large number of practicing physicians, especially in the North region (includes the United States, Canada, Bermuda, Greenland, and Saint Pierre and Miquelon), results in a continent-based density of 2.2 physicians per 1000 inhabitants.

남아메리카에는 218의 의과대학이 있다.

There are currently 218 medical schools operating in South America. With a 2004 population of 366 million, this represents one medical school for every 1.7 million inhabitants. 

아프리카에는 127개의 의과대학이 있으며 8억7천3백만명이 살아서 690만명당 1개의 의과대학이 있다.

In Africa, where there are only 127 listed medical schools and a population of 873 million, there is one medical school for every 6.9 million inhabitants, and only 231,426 total physicians. As a result, physician density is particularly low, with about one doctor, on average, for every 4000 people. In Western, Eastern and Middle Africa, where there are relatively few medical schools for the given population, physician density is also extremely low, averaging about 0.12 per 1000.

의과대학 밀도와 의사 밀도 사이에는 강한 상관관계가 있다. 유럽과 아프리카는 그 극과 극을 보여준다.

In general, there is a reasonably strong relationship, at least at the continent and regional levels, between medical school density and physician density (Pearson correlation (region) = 0.64). Europe, with approximately one medical school for every 1.9 million inhabitants, has a physician density of 3.4/1000. At the other extreme, Africa, with one medical school for every 6.9 million inhabitants, has a physician density of 0.26/1000. 

그러나 지역 수준에서 이러한 상관관계는 대륙 수준의 상관관계만큼 높지는 않다.

At the regional level, however, some of the relationships are not as strong. Eastern Europe, with 127 medical schools and a population of approximately 300 million, has one medical school for every 2.4 million inhabitants, a comparatively small ratio when contrasted with other European regions. However, with over one million doctors, physician density is relatively high at 3.6/1000. In contrast, the Caribbean has the most medical schools per unit population (1.4/million) but a physician density (2.3/1000) that is comparable to that of the North region of North America (0.5 medical schools/million population; physician density = 2.5/1000).

인구가 4백만 이상인데 의과대학이 없는 국가는 거의 없다. 있긴 있다.

There were relatively few countries with populations of greater than four million that had no medical schools. 

These included Eritrea and Somalia, both in Africa. In total, of the 57 African nations, 16 did not have a single medical school. 

반대로 인구는 작지만 둘 이상의 의과대학을 보유한 국가도 있다.

In contrast, there are several countries with small populations that have one or more medical schools. 

Countries with operating medical schools and populations of less than two million are presented in Table 3. The Netherlands Antilles, with a resident population of approximately 218,000, has six operating medical schools, yielding an average of one medical school per 36,000 individuals. Similarly, Belize, with a relatively small population of 270,000, has six medical schools. Montserrat, with a resident population of fewer than 10,000, has two medical schools.

Although some general information is available in IMED for institutions in the US and Canada, the database is focused primarily on international medical schools. 

언어 : Of the 1771 medical schools located outside the US or Canada, 664 (37.5%) offer instruction in English. However, only 22% of the countries where these schools are located list English as an official language. Within the group of schools where English is not a language of instruction, the most common teaching languages were Spanish (21%), Chinese (12%), French (8%), Portuguese (8%), Japanese (7%) and Russian (6%). 

교육과정 : The minimum curriculum duration is four years; the maximum is eight years. Based on the cohort of international medical schools, 1620 (91%) have information listed as to when the medical program started. 

설립시기 : A total of 202 medical schools started in the nineteenth century or earlier. Between 1900 and 1949, 235 medical schools began training students. Between 1950 and 1999, 1062 medical schools were created. This influx represents approximately two-thirds of all currently operating international medical schools. 

The largest relative growth (1950–99) was experienced in South America, where 153 (of 193 schools with a verified start date) began operations. In Brazil, 66 (83% of the schools with a verified start date) began operating between 1950 and 1999. 

A similar expansion (1950–99) occurred in Asia, where 577 (73%) of the 794 Asian medical schools with a verified start date began operating. In China, 104 schools (82%) were created between 1950 and 1999. 

Most recently (2000–present), some of the largest relative growth occurred in Oceania: seven schools began training physicians, representing 32% of 22 listed medical schools for this continent. 

IMED : In Asia, 76 medical schools were added to IMED in 2000 or later. Most of this growth could be attributed to India, where 46 schools either started operations or achieved recognition. In terms of recent overall counts, China also had a large country-based growth in medical schools: 14 schools were recognized and added to IMED between 2000 and 2006. From a regional perspective, the Caribbean has also seen a large recent growth in the number of medical schools. Between 2000 and the present, 13 medical schools were added to IMED, including, amongst others, five in Belize, three in Saint Lucia and two in Aruba.

고찰

Discussion

Based on IMED listings, there is a fairly wide dispersion of medical schools throughout the world. Interestingly, nearly half of all the medical schools are located in 10 countries. While some of these 10 countries have relatively large populations (e.g. China, India), and would logically have numerous educational institutions, some do not (e.g. Iran). From a physician production perspective, this would suggest that, at least for some counties or regions, the distribution of medical schools may not be keyed to local needs. Even if medical school training programs were developed to satisfy national or regional requirements, migration may have a significant impact on local physician density. 

For example, although there are 219 operating medical schools in India, physician density within the south-central Asian region is only 0.65/1000, about half of that for the entire world. 

While part of this can be explained by the relatively large population, almost 60,000 Indian physicians practice in the US, United Kingdom, Canada and Australia (Mullan 2006). These Indian-trained doctors are the largest émigré physician workforce in the world. 

의사 양성과 국가 수요간의 관계를 그리는 것은 복잡하고 다면적이다.

Mapping the relationship between physician production and national requirements is, however, complex and multidimensional. 

First, the population (or population health)–medical school relationship is certainly dependent on medical school class size, curriculum focus (e.g. public health), and clinical experiences of the graduates. While the variability in class sizes would tend to average out over large regions, this is unlikely to be the case at the country level, especially for nations with relatively few medical schools. 

Second, for some schools, physician training, to some extent, is certainly not directed primarily towards addressing local supply. Nevertheless, provided that these physicians go to areas of need, the physical location of the medical school may not be that important. 

Finally, although physicians are extremely important in any healthcare delivery model, the role of other practitioners (e.g. nurses) and advanced technology will certainly have some impact on resource needs.

의과대학과 의사의 분포가 균등하지 못한 것은 자명해보인다.

The more detailed analysis, by continent and region, of medical schools by population and physician density clearly shows that medical schools and physician resources are not dispersed uniformly. 

6%의 인구에 14%의 의과대학이 있는 남아메리카의 경우, 캐리비안의 의과대학 비율은 확실히 높은 편이다.

For example, over 11% of the world's medical schools are located in South America yet less than 6% of the world's population resides there. In contrast, nearly 14% of the world's population resides in Africa, an area serviced by only 127 medical schools. From a regional perspective, the Caribbean clearly has a disproportionate number of medical schools. Historically, of the 25 Caribbean nations, 24 had an operating medical school at one time or another. Currently, there are 54 operating Caribbean medical schools, located in 16 different countries. The concentration of schools in this region is not surprising given the large number of American citizens who travel there for their medical education (McAvinue et al. 2005). In addition, physician density in this region is comparable to that for North America, suggesting that the medical education programs do, at some level, provide for local needs. 

However, more important than the excess of ‘offshore’ schools, there are some populated countries (e.g. Somalia), including 15 other nations in Africa, with no medical schools. While the physician workforce needs of these nations could potentially be met by other countries, there is no guarantee that other nations, especially those in Africa, could afford to lose their local doctors. Although efforts to redistribute, or create new, medical schools may alleviate some of the local supply problems, at least temporarily, a more pressing concern is physician migration (Cooper 2005; Hagopian et al. 2004). In essence, while the location of the medical school is fixed, the practice locations of medical school graduates are not.

의사들의 이주가 크게 영향을 주는 요인이긴 하나, 의과대학 밀도와 의사 밀도가 관계가 있다는 것은 적어도 지역 차원에서는 확실해보인다.

While physician migration certainly plays a role in the worldwide distribution of physicians, there remains a strong relationship, at least regionally, between medical school density and physician density. 

유럽의 예를 들면 인구에 비해서 의과대학이 많으며 의사 밀도도 높다. 의과대학 수를 늘리는 것이 해당 지역의 의사 밀도를 높이는데 기여할 것이다.

In Europe, for example, there are a large number of medical schools (n = 394) for the population, and a sizeable physician density of 3.4/1000. Although the medical school–physician density relationship is complex and time-lagged, dependent on migration patterns and questionably causal in nature, it would still suggest that increasing the number of medical schools in low-density areas should lead to overall increases in physician density. 

일부 국가에서, 즉 인구는 많은데 의과대학이 적은 국가에서는 국가 내에서 의사를 양성함으로서 의사 밀도를 높일 뿐만 아니라 국외 의사에 대한 의존을 낮추고 해외로 수련을 나간 의사들이 가질 수 있는 불확실성을 낮춰서 지역 인구의 건강에 기여할 수 있을 것이다.

For some countries, especially those with large populations and relatively few, if any, medical schools, training some physicians within the country, especially if migration can subsequently be curtailed, will serve to increase physician density. This will also curb dependency on expatriate doctors, quell uncertainties about the return of nationals sent abroad for training, and build a workforce that can provide proper healthcare for the local population (Broadhead & Muula 2002; Muula 2006).

The analysis of IMED data points to rapid growth, internationally, in the number of medical schools in the second half of the twentieth century. This surge in the number of medical schools probably corresponds to global economic and population growth, especially in developing countries such as India and Brazil. Whether or not this trend will continue is unknown. Based on IMED data collected since 2000, China (>10%), India (>25%), and the Caribbean (>40%) have seen substantial increases in the number of IMED listed medical schools. As the demand for healthcare service increases, other counties/regions are bound to expand enrollment at existing institutions and/or build new schools (AAMC 2006). For the purpose of global workforce planning, tracking this growth, and determining the relationship between physician training and local healthcare needs, is extremely important.

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Med Teach. 2007 Feb;29(1):20-6.

An overview of the world's medical schools.

Boulet J1, Bede C, McKinley D, Norcini J.

Author information

Abstract

BACKGROUND:

In the past several years, there has been a rapid expansion in the number of medical schools. Presently, there are over 1,900 operating medical schools in the world, located on six of the seven continents. Regrettably, other than for select countries and regions, relatively little is known about the characteristics or the quality of these institutions.

DESCRIPTION:

The International Medical Education Directory (IMED) provides an accurate and up-to-date resource of information about medical schools. Based on current listings in IMED, the geographical distribution of medical schools does not mirror the regional population. The Caribbean, with a total population of less than 40 million, has 54 operating medical schools. In contrast, of the 57 African nations, 16 did not have a singlemedical school.

CONCLUSIONS:

Given the physician's role in the healthcare team, the challenges presented by migration of healthcare workers, and questions concerning the adequacy of existing institutions to meet healthcare needs, developing and maintaining accurate and detailed information on the world's medical schools and their graduates is paramount.

Comment in

• Medical schools--do they add value? [Med Teach. 2007]