플렉스너 보고서 이후 남아시아(South Asia)의 의학교육

Relevance of the Flexner Report to Contemporary Medical Education in South Asia

Zubair Amin, MD, MHPE, William P. Burdick, MD, MSEd, Avinash Supe, MS, PGDME,

and Tejinder Singh, MD, MHPE

플렉스너보고서가 미국 의학교육의 실태를 묘사한지 100년이 지나고 난 이후, 아시아의 많은 지역이 비슷한 곤경에 빠져 있다. 사립 의과대학의 수가 폭발적으로 늘어나고, 교육의 질에 대한 의구심이 커지고 있다. 규제가 제대로 되지 않는 의과대학이 남아시아 의학교육의 질과 수준을 위협하고 있다. 미국에서 플렉스너가 그랬던 것처럼, 학생이 서로 돈을 내기 위해서 경쟁하고, 효과적이지 못한 인증 과정이 입학절차에 대한 의문을 품게 했으며, 교육과정이 정체되었고, 낡은 학습방법을 사용하고 있고, 평가방법 역시 의심스럽게 하는 상황이다. 인증 시스템은 미국에서도 19세기에는 취약한 부분이었던 것처럼, 현재 아시아의 많은 국가에서 제한적이며 그 이유로는 적절한 권한을 가진 기구가 없고, 자원이 없고, 제대로 enforcement되지 않으며, 종종 발생하는 부패가 원인이라고 할 수 있다. 인도에서는 현재의 의과대학 인증 시스템에 대하여 불만이 터녀자와 인도의 Medical Council을 재조직하라는 국가적 요구가 나오고 있는 상황이다.

One hundred years after the Flexner Report 1 described the condition of medical education in the United States, medical education in a large part of Asia is in a similar predicament, with an explosion of private medical schools and questions about the quality of education. Weakly regulated growth of medical schools now threatens the quality and standards of South Asian medical education. As in Flexner's United States, competition in South Asia for students' fees and an ineffectual accreditation process have resulted in questionable admission practices,2 stagnant curricula,2,3 antiquated learning methods,2,3 and dubious assessment practices.2,4 Accreditation systems, which were weak in 19th-century America, are constrained in much of Asia by a combination of inadequate authority, insufficient resources, uneven enforcement, and occasional corruption.2,3,5,6 Dissatisfaction with the current accreditation system in India has led to a national commission's proposal for major reorganization of the Medical Council of India, the regulatory body for medical schools.7

이 문헌의 목적은 플렉스너의 관찰 결과와 현재의 남아시아 상황의 관련성을 찾아보는 것이다. 

The purpose of this article is to examine the relevance of Flexner's observations to contemporary medical education in South Asia. We review the contexts of Flexner Report, present the commonality of key factors in the recent and prolific growth of medical education across South Asia, and analyze the consequences of these factors. Our overarching aim is to bring the attention of the global audience to a developing issue that could potentially affect countries beyond the borders of South Asia.8,9

 

지정학적 위치 및 용어 정의

Geographic Area and Clarification of Terminology

여기서 다루고자 하는 남아시아에 해당하는 국가는  India, Pakistan, Bangladesh, Sri Lanka, Nepal, the Maldives, and Bhutan 등이다. 이 국가를 다 합하면 전 지구 인구의 1/5에 달한다. 이 지역을 선택한 이유는 다음과 같다. 

첫째, 남아시아 국가들은 현재 사립의과대학의 급증 문제를 가장 크게 안고 있는 나라이다. 

둘째, 인도와 다른 남아시아 국가들은 선진국에 의사를 공급하는 국가들이다. 

셋째, 이 국가들은 경제적 전환기에 있으며, 고등교육에 대해서 비슷한 문제들을 안고 있다.

The primary focus of this article is South Asia, one of the five regions in Asia recognized by the United Nations. The countries in this region are India, Pakistan, Bangladesh, Sri Lanka, Nepal, the Maldives, and Bhutan. Together they are home to one-fifth of the world's population.10 The reasons for our deliberate choice are several. First, South Asian countries are more likely to be affected by problems resulting from rapid growth of private medical education than are more developed countries.11 Second, India and several other South Asian countries are the major suppliers of international physicians to the developed world.12,13 Third, these countries are transitional economies,11 and they face common challenges related to higher education.14,15

 

비록 중국이 아시아의 주요 국가이긴 하지만, 분석에서는 제외했다. 왜냐하면 중국은 사랍, 영리 의과대학을 제한하고 있기 때문에 다른 아시아국가가 겪는 사립의과대학의 증가 문제에서 비교적 떨어져 있기 때문이다.

Although China is a major country in Asia, we excluded it from our analysis. We took this step because Chinese regulations prohibiting private, for-profit medical schools have kept China from experiencing the growth of private medical schools that has been seen elsewhere in Asia.16,17

 

정부가 운영하는, 공립의 의과대학은 정부로부터 많은 자금 지원을 받는다. 사립 의과대학은 비정부 재원으로부터 지원을 받는데, 여기에는 학생이 내는 등록금, 환자가 내는 비용, 동문의 기부금 등이 있다. 많은 사립 학교는 영리기관이나 전부가 그런 것은 아니어서 일부는 profit-neutral하거나 not-for-profit 기관도 있고, 일부는 mission-oriented 학교들이다. 자선 또는 비영리 조직에 의해서 세워진 의과대학은 '사립' 이라는 명칭보다 'nongovernmental'이라는 명칭을 더 선호한다. 그러나 대다수의 사립 의과대학에서 '영리'는 겉으로 표방하는, 혹은 숨기는(implicit)목표이며, 이러한 학교들은 플렉스너가 말한 '상업적'의과대학과 다를 바 없다.

Government-run, or public, medical schools are those that receive substantial funding from governmental sources, including state funds. Private medical schools are funded primarily from nongovernmental sources, including direct tuition, patient fees, alumni donations, and obligatory surcharges such as the development fund imposed on a school's students. Many private medical schools are profit-driven, but not all. Some are profit-neutral or not-for-profit, and a few others are mission-oriented. Medical schools established by charitable or nonprofit organizations prefer the term “nongovernmental,” rather than “private,” to emphasize their nonprofit nature. However, for the vast majority of private medical schools, profit is an explicit or implicit goal, and these schools are very similar to the “commercial” medical schools described by Flexner.11,18

 

플렉스너 보고서가 나온 당시의 상황

The Context for the Flexner Report

 

19세기 미국에서 의학교육은 도제식 모델에서 그룹 교육 모델로 이행하는 중이었다. Civil War 시기를 지나면서 의사 교육과 의사의 질에 대한 몇 가지 문제가 드러났고, 이 시기동안 군은 지원하는 의사의 1/4을 탈락시켰다. 프랑스의 '관찰식 시스템' 또는 독일의 '실험 시스템' 아래서 교육받은 의사들은 미국으로 돌아오고 있었으나 미국의 체계적이지 못하고 과학적이지 못한 의학교육에 환멸을 느꼈다. 대부분의 교사들이 '그냥 의사(practitioner)'였고, 매우 소수의 교수(academic faculty members)는 소수의 의과대학(university affiliated medical schools)에 집중되어 있었다. 대학과 협력(associated)하고 있다고 '이름만 내건' 상업적 의과대학이 엄청나게 증가하고 있었고, 이들의 양질의 의학교육을 저해하는 주범이었다.

In 19th-century America, medical education was undergoing a transition from an apprenticeship model to a group-teaching model. Severe inadequacies in physician training and quality were exposed by Civil War medical practice, and, during that war, the military rejected one quarter of the physicians who applied to serve.19 U.S. physicians who were trained in the French observational system or the German experimental system were, on their return to the United States, disillusioned by the lack of systematic and scientific rigor in medical education.19,20 Most teachers were practitioners, and a small number of academic faculty members were concentrated at a few university-affiliated medical schools. Prolific growth of commercial medical schools, which usually were associated with universities in name only, overshadowed the few high-quality medical schools.1,19

 

허술한 규제가 돈을 내고 의사가 되려는 학생들의 시장주의적 관점과 합해져서 의과대학의 폭발적 증가를 이끌엇다. 주립 면허제도가 있었으나, 일반적으로 미미하고 효과가 없었다. 의과대학과 의사들은 부유한 지역에 주로 밀집되어 있었다.

Lax regulation, coupled with a growing market of prospective students who had the means to pay for an education and who were looking for a career opportunity, created the conditions for explosive growth of medical schools.1,19 State licensing boards existed, but, in general, they were weak and ineffective; in some cases, they were outright corrupt.20 Medical schools and doctors were largely concentrated in wealthier regions, drawn there by financial opportunity.1

 

플렉스너 보고서 이전의 미국에서 '의사의 부족'이란 없었다. 사실 플렉스너는 '과도한 의사 공급'을 더 걱정하고 있었다. 보고서에 따르면 568명당 1명의 의사가 있었으며, 이는 당시 유럽의 의사수(2000명당 1명)보다 훨씬 높은 수준이었다. 의과대학을 폐쇄해야 한다는 그의 제안은 '이 나라는 더 소수의 더 나은 의사가 필요하다' 라는 주장과 일맥상통하는 것이다.

In the pre-Flexner United States, there was no shortage of doctors; in fact, Flexner was more concerned about an oversupply. He reported a density of one doctor for every 568 people, which was significantly higher than the density in Europe at the time (about one doctor for every 2,000 people). His recommendation to close schools was consistent with his assertion that “the country needs fewer and better doctors.”1

 

19세기 말, 의사소통의 향상은 변화의 촉매가 되었다. 산업혁명의 steam engine으로 세계는 더 작아졌다. 대서양을 건너는 시간은 1840년 5주, 1860년에 12일, 1910년엔 9일로 줄었다. 배는 더욱 안전해졌다. 승객 사망도 90%정도 감소하였다. 이러한 것은 유럽에서 미국으로 사상(idea)가 흘러 드러오는데 큰 기여를 하게 된다.

At the end of the 19th century, enhanced communication was a catalyst for change. The world was becoming smaller in the 1880s, thanks to the introduction of the steam engine during the Industrial Revolution. Transatlantic transit time was reduced from five weeks in 1840 to 12 days in 1860 and then further shortened to 9 days by around 1910, as steamships replaced clipper ships. Ships also became much safer because of the shorter transit time and the use of metal hulls; passenger mortality declined by 90% little more than a decade after the introduction of faster steamships,21 which further facilitated the flow of ideas from Europe to America.

 

다양성 속의 공통성

Commonality in Diversity

아시아는 엄청난 다양성을 품은 대륙이다. (고등교육, 의료접근성, 경제 발전, 건강과 교육요구 등등). 또한 의학교육의 발전 역시 각 국가의 역사적 맥락, 국가 개발 노력, 현 글로벌 추세 등에 영향을 받는다. 그러나 거의 모든 아시아 국가는 사립 교육의 빠른 확장이라는 도전에 직면하고 있다. 

Asia is an immensely diverse continent in terms of factors that affect the development of higher education, such as the sociopolitical structure of each country and its access to health care, economic advancement, and health and education needs.5,14,18 In addition, the development of medical education has been greatly influenced by each country's historical past, nation-building efforts, and current global trends.14,18 However, nearly all Asian countries face common challenges due to the rapid expansion of private education.5,14

 

남아시아 국가들은 경제 체제가 바뀌면서 정부의 중앙집권적 시스템에서 조금 더 liberal하고, 시장주의적 시스템으로 옮겨가고 있다. 중앙집권적 시스템에서는 다양한 분야에서 정부의 규제가 작용한다. 또한 지역간 인구밀도라든가 소득의 공평성에 대한 대중의 관심이 있다고 하더라도, 이렇게 경제 체제가 변화하는 시기에는 좀 더 경제와 규제가 liberalized되어 '기회의 균등을 이야기하지 않으며, 차이(differentiation)는 받아들여야 하는 것일 뿐만 아니라 오히려 권장된다' 라고 한다.

Transitional economies, such as those found in South Asian countries, are characterized by an abrupt move from a centralized system of governance to a more liberal, market-driven system. In centralized systems, a high degree of control is maintained over various facets of education, such as admission criteria, faculty recruitment and retention, and curriculum structure.11 Although there is a public interest in maintaining equity between different geographic regions according to population density and income,11 as economies and regulation are liberalized in many transitional economies, “there is no talk about equality of opportunity; differentiation is not only admitted but encouraged.”22

또 다른 공통적 요소는 고등교육에 대해 대중이 지불하는 비용의 감소이다. 1985년부터 1997년까지 사립 의과대학이 가장 빠르게 증가하였는데, 이러한 경제적 이행 시기에 있는 아시아 국가에서 정부의 GDP대비 교육 지출이 감소하였다. 

Another common element has been a decrease in public spending on higher education. From 1985 to 1997, the era that heralds the most rapid growth of private medical schools, government spending on education as a percentage of gross domestic product (GDP) declined in many transitional Asian economies.11 

For example, during this period, government spending as a proportion of GDP declined in China from 2.5% to 2.3%, and in South Asia it declined from 3.4% to 3.3%. By contrast, in high-resource economies, such as North America and Europe, the corresponding percentage in 1985 was almost twice as high as that in Asia, and it has actually increased since that time.11 

대부분의 아시아 국가들이 심각한 의사 부족 문제가 있음에도 교육에 대한 공공 지출은 줄어들고 있다. 

Public funding for education diminished, despite the fact that most Asian countries have concurrently faced a serious shortage of physicians. For example, in China, Pakistan, India, Bangladesh, and Indonesia, there is, today, one doctor for every 943, 1,351, 1,667, 3,846, and 7,692 people, respectively,23 a density considerably lower than that in pre-Flexner America.

 

규제가 약하고, 수요가 증가하고, 중앙의 재정지원과 통제가 없는 상황에서 '부패'는 질을 악화시키는 또 다른 공통적 요인이다. 2008년 부패인식지수 보고서에 따르면 이들 국가는 거의 최악의 국가에 속한다. 이들 국가들이 바로 사립 의과대학이 가장 빠르게 늘어나는 국가이기도 하다. 

In an environment of weak regulation, increased demand, and diminishing central funding and control, corruption may be another common factor leading to inappropriate growth and poor quality.24 In its 2008 report on the Corruption Perception Index, Transparency International 25 identified Bangladesh, India, Indonesia, Nepal, Pakistan, and the Philippines as having among the worst scores in the world. These countries also demonstrated the most prolific growth of private medical schools, which highlights the potential relationship between corruption, political influences, and commercialization of education.

 

사상의 공통성과 당면과제의 공통성이 통신기술의 발달로 더 가속화되었다. 인터넷 접근성, 휴대폰 사용 등이 남아시아 내에서, 그리고 남아시아와 여타 다른 국가들 사이의 생각의 흐름을 가속화시켰다. 이러한 효과는 플렉스너 보고서 이전에 대서양을 횡단해오는 사상의 흐름이 빨라졌던 것과 유사하다.

Commonality of ideas and issues has also been accentuated by advances in communication. Internet access 26 and mobile phone use 27 have accelerated the diffusion of ideas within South Asia and between South Asia and the rest of the world. This effect is similar to that of faster transatlantic movement and other innovations that preceded the publication of the Flexner Report.

 

빠른 성장과 그 결과

Rapid Growth and Its Consequences

 

이렇게 경제 발전, 중산층 증가, 직업으로서 의학의 매력 증가 등이 불러온 사립 의과대학의 증가는 19세기 초반 미국의 모습을 떠올리게 한다. 플렉스너는 "그 날 이후 의과대학은 규제 없이 마구 늘어났고, 분열하듯 늘어나고 있다"

The prolific growth of private medical schools, driven by economic development,28 the expansion of the middle class,29 and the attractiveness of medicine as a career,2 mirrors that in the United States in the early 19th century, as highlighted eloquently by Flexner 1: “Since that day medical colleges have multiplied without restraint, now by fission, now by sheer spontaneous generation.”

사립 의과대학이 남아시아 전역에서 늘어나고 있다.  

Private medical education is burgeoning throughout South Asia. 

India, whose private medical education system is one of the most rapidly expanding such systems in the world, is a prototypical example of market-driven growth. Between 1970 and 2005, the number of private schools multiplied by a staggering 1,120%. Private medical schools now account for half of all available admission seats 30; in 1970, they accounted for only 11%. India has 289 medical schools with 31,698 seats; 205 of these 289 schools were fully recognized by May 2009.31 Similar trends have emerged in other countries. 

In Bangladesh, 32 new private medical schools have been established in the past 10 years, and the combined student enrollment in private medical schools now exceeds that in governmental medical schools.32 

In 1981 in Pakistan, there were 16 medical schools, all of which were public. The first private medical school in Pakistan opened in 1983. Between 1997 and 2005, the total number of medical schools in that country doubled—there are currently 57 approved medical schools, 32 of which are private.33,34

 

그러나 이러한 증가에 불균형이 심각하다. 대부분의 사립의과대학은 도시의 부유한 지역에 쏠려 있다.

However, the growth has been lopsided. Most private medical schools are concentrated in the urban areas of wealthier states in India, where there is a better market for costly private education.2,30 In Bihar, one of the poorest states in India, the six medical schools in existence in 1990 increased to eight schools by 2006, with the addition of two private schools. By comparison, the state of Maharastra, with about the same population as Bihar, had 12 medical schools in 1990 and 39 in 2006, 20 of which were private.35 Eighty-eight of the 100 private medical schools in India are located in states whose average per capita income is above the median for India; 60% of the public schools (74 of 121 medical schools) are also located in those states. Seventy-five percent of new doctor registrations at state medical councils, a marker of a graduate's intention to practice in a specific area, also are recorded in the wealthier states.30 This difference further exacerbates the urban–rural divide in higher education and in medical education in particular.36 There is little incentive for private medical schools to operate in areas of the greatest need.2,30

 

교수 수 부족

Shortage of faculty

 

예상할 수 있는 것처럼, 급격하게 교수가 부족해졌다.

Predictably, rapid growth has created an acute shortage of faculty.

 For example, in India, for medical school programs alone, there currently is an estimated need for an additional 26,000 full-time faculty, a gap that will be very difficult to close in the near future.37 This shortage has been compounded by other factors, such as the migration of faculty to higher-paying schools and countries 12,33,38 and the loss of teaching faculty to dental schools.37,39 Moreover, as in Flexner's time and much as in U.S. medical schools today,40 it is common for “full-time” teaching faculty also to engage in private clinical practice, which potentially diminishes their availability to the school for teaching. In addition, some “full-time” faculty are simultaneously employed as part-time faculty at private schools—an arrangement that not only supplements their income but also helps the private school present the appearance of a full roster of faculty.41,42

 

교수 수 부족은 특히 전임상 교실과 senior 레벨에서 심하다.

The need for additional faculty is more pronounced in preclinical departments and at senior levels.37 

For example, in India, the number of anatomy teachers required for undergraduate and postgraduate courses, according to Medical Council of India-mandated ratios, is 1,888. With an estimated attrition rate of 25% per year, 470 new anatomy faculty members are needed annually, yet only 170 new anatomy faculty join the existing pool each year, which contributes to an ever-increasing deficit.37 Fraudulent faculty rosters are common enough in some countries that regulatory inspectors usually demand that faculty be present in a room to be physically counted,42 even though this process frequently disrupts teaching, research, or faculty development activities.

 

임상 실습 기회 부족

Inadequate clinical exposure

 

적절한 수준으로 환자 경험을 쌓지 못하는 것이 플렉스너 시대에 미국이 가진 한 가지 문제였고, 현재 남아시아에서도 마찬가지다. 플렉스너는 의과대학과 병원이 매우 제한적인 관계만 유지하고 있다는 것을 지적하면서, 이것이 바로 의과대학이 교육과 연구에 신경을 쓰지 않는다는 한 가지 근거라고 보았다. 존스홉킨스 같은 매우 예외적인 경우를 제외하면 대부분의 의과대학은 학생이 환자 실습을 할 수가 없었다. 그 결과 대부분의 학생은 졸업 전에 환자를 본 경험이 없었다. 

Adequate patient contact was a problem in the United States in Flexner's time and is a problem in South Asia today. Flexner described a limited relationship between medical schools and hospitals, which did not see their mission as including education or research. With the notable exception of Johns Hopkins, most schools, including very prestigious ones, could not get hospitals to agree to allow medical students to have access to patients. As a consequence, most students had little or no contact with patients before graduation.1,19 

남아시아 국가의 사립 의과대학 학생들도 비슷한 수준이지만 이유가 조금 다르다. 비록 이들 의과대학이 공립 의과대학보다 더 재정도 튼실하고 등록금도 많이 받으며, 따라서 교수들도 더 높은 봉급을 받지만, 학생들이 환자를 보지 못하는 이유는 대부분의 환자들이 보험이 되지 않는(nonsubsidized) 가격의 진료를 받을 경제적 여력이 없기 때문이다. 따라서 자선 기관 또는 미션스쿨이 예외적인 경우가 된다.

Students at private medical schools in South Asian countries also suffer from limited clinical experience, but for different reasons than pertained in the United States in Flexner's time.2 Although many of these schools may be better funded than government schools because of higher tuition receipts, and, thus, their faculty are better-paid, they often lack access to patients, because most of the population cannot afford the nonsubsidized prices for health care.43 An exception can be found in the charitable private institutions or mission-based medical schools that offer subsidized care. The result, as in the pre-Flexnerian era, is limited exposure to patients.

 

이렇게 학생들의 임상 경험이 부족한 것을 속이기 위해서 학교들은 건강한 사랍들을 입원시켜서 정부 인증단이 방문평가를 왔을 때 '환자' 숫자에 포함시킬 수 있도록 거짓 보고를 한다.

In an attempt to fraudulently misrepresent the opportunities for clinical experience by their students, schools have been reported as placing healthy people in hospital beds to give the appearance of adequate clinical access when government accreditors count “patients” during their site visits.44

 

레지던트 교육의 상업화

Commercialization of postgraduate (residency) education

 

사립 의학교육이 성정하면서, 지금까지는 대체로 학부교육에 집중되었던 것이 졸업후교육에까지 영향을 주고 있다. 남아시아 국가에서는 학부 학위과정을 마친 학생의 숫자와 졸업후 레지던트 교육을 받을 수 있는 의사의 숫자 사이에 심각한 불균형이 있다. 예컨대 인도에서는 의과대학 졸업생 중 29%만이 레지던트 수련을 받을 수 있다.

Growth in private medical education, which so far is largely concentrated at the undergraduate, or medical school, level, is now starting to occur in postgraduate education. In South Asian countries, there is a significant mismatch between the number of students completing the MBBS (MD) course and the number of postgraduate seats: 

in 2006, residency positions in India were available to only 29% of the graduating medical school class.35 The Jawaharlal Institute of Postgraduate Medical Education and Research recently had 400 applications for two postgraduate positions in cardiology.45 

Nepal, with a population of 28.6 million,10 graduated only 208 physicians from postgraduate programs in the 10 years from their inception in 1994 to 2004.46 With this level of unmet demand, postgraduate education, which traditionally provides on-the-job training experience, has become a fee-paying enterprise. 

At one Indian university, fees range from $16,000 for a two-year “PG [postgraduate] diploma” program to $57,000 for a three-year “MD” postgraduate program.47 Fees for nonresident Indians are higher, ranging from $83,000 to $114,000 for clinical “MD” programs.48 

지금까지, 인도에서는 '돈을 지불하는' 레지던트 교육으로의 흐름이 두드러지며, 다른 국가로도 퍼져나가고 있다.

So far, the trend of fee-paying postgraduate education is most noticeable in India. However, with similar forces in play elsewhere in Asia, this trend may spill over to other countries.

 

단순암기식 교육 강조

Emphasis on rote learning

 

플렉스너는 교수가 롤모델이 되고, 학생이 스스로 의사가 될 준비를 하는 자발적 학습을 강조했다. 그러나 현재 아시아에서는 고도로 금지적인(proscriptive) 인증 기준이 시설의 세부까지를 규정하고, 교육과정 시간을 정하고, 평가 가이드라인을 강제하면서 낡은 방법과 주제에 교육을 가두고 있다. 그 결과 교육 방법은 과거에 머물러있고, 플렉스너 시기의 교육과 다를 바가 없다.

Flexner recognized the importance of active learning and inquiry by the faculty as role models and by students in preparation for their work as practitioners.1 In Asia today, static, highly proscriptive accreditation standards frequently specify infrastructure details, delineate detailed curriculum hours, or dictate assessment guidelines that lock in outdated methods and topics.49 As a result, teaching methods have become frozen in time, and that frequently results in conditions quite similar to those described by Flexner.2,39

플렉스너의 사고방식은 존 듀이의 업적에 영향을 받았다. 교수는 열린 자세로, 질문하는 마음가짐으로 학생에게 영감을 심어줄 수 있어야 한다. 

Flexner's thinking was influenced by the work of John Dewey, a strong proponent of active inquiry. “Out-and-out didactic treatment is hopelessly antiquated,” Flexner 1 wrote. “It belongs to an age of accepted dogma or supposedly complete information, when the professor ‘knew’ and the students ‘learned.’” Flexner argued that the faculty needed to embody the connection between investigation and clinical practice and, therefore, needed to embrace an open-minded, questioning spirit, in order to instill it in their students.50

 

플렉스너의 자발적 학습에 대한 철학이 현재 미국에서는 광범위하게 받아들여지고 있으나 아시아에서는 그렇지 않다. 아시아에서는 나이 많은 사람에 대한 존경이 매우 중요한 가치이며, 교수들은 전문가의 의견과 단순 암기가 팽배한 권위적인 교육 시스템 속에 있다. 더 나아기 행정가는 제한된 예산 속에서 국가가 '처방한' 교육과정을 맞추느라, 대규모 강의를 선호한다. 많은 열악한 사립학교는 지식이 부족한 파트타임 교사를 고용하고 있다.

Whereas Flexner's philosophy of active learning is broadly accepted in the United States today, such is not the case at most medical schools in Asia, where passive lecture-based teaching is still the norm. In parts of Asia where respect for elders is a deeply held value, medical teachers remain committed to a more authoritarian and didactic system of teaching, in which expert opinion and rote learning of facts prevail.2,3,32,35 Moreover, administrators, eager to meet requirements of the prescribed national curriculum and working on a tight budget, prefer large-group teaching rather than the more resource-intense small-group format. Many poorly run and inadequately equipped private medical schools deliver their curricula by using part-time teachers who lack necessary knowledge about the broader curricula.42

 

현재 남아시아에 플렉스너 보고서가 주는 교훈

Implications of the Flexner Report for Contemporary South Asia

 

플렉스너 보고서가 나오던 시기의 미국의 상태, 그리고 현재 아시아의 상태는 비록 한 세기가 떨어져 있지만, 플렉스너가 1910년 제안한 것을 도입하는 것을 고려해볼 만 하다. 이 제안에는 다음의 것들이 있다.

Although conditions in the United States at the time of the Flexner Report and in contemporary Asia are separated by a century and a continent, many of the conditions are sufficiently similar that adaptation of some of Flexner's 1910 recommendations should be considered for South Asian medical education today. These recommendations include 

(1) create a stronger and more meaningful accreditation process to ensure the quality of medical schools, 

(2) establish health professions education as a recognized field of study, and 

(3) address the faculty shortage through a system of faculty development.

 

인증 강화

Strengthen accreditation

의과대학 인증은 의과대학의 질을 담보하는 한 가지 기전이다.  

Accreditation serves as a quality assurance mechanism promoting professional and public confidence in the quality of medical education, assists medical schools in attaining desired standards, and ensures that the performance of a school's graduates complies with national norms.51,52 It should be flexible enough to accommodate innovative programs and should use research and evaluation of education methods to periodically adjust standards.53

인증 기준에 있어서 '결과물' 뿐만 아니라 '과정' 에 대한 기준을 두는 것이 중요하다. 

It is important that accreditation standards include both outcome and process standards.51,52,54 

Outcome standards assess the product of an education system and ask whether the graduate is capable of meeting certain uniform thresholds for knowledge, skills, and attitudes. However, education is not simply about passing a set of tests; it involves a much richer tapestry of interactions and learning that are not likely to be captured by an imperfect assessment system.55 

Therefore, process standards are necessary for review of the methods of selection, education, student evaluation, and promotion used by the education institution. The setting of these standards may be aided by looking outside Asia to international standards such as the standard created by the World Federation of Medical Education.56 These standards focus on the process of medical education and can serve as a template for building national or regional standards.

이러한 기준은 지속적으로 적용되고 계속 개정되어야 효과가 있다. 기관이 재체평가를 하고, 평가단이 방문 평가를 해서 삼각자료수집(triangulated data collection)을 해야 한다.

Quality standards are useful only if they are meaningfully and consistently applied and regularly updated.52,57 Institutional self-assessment, site visitation with collection of triangulated data by trained reviewers, and stringent ethical standards for the accrediting body will promote confidence in the process and stimulate the development of a culture of improvement at schools.54 Accreditation standards are not static, and they should be frequently revisited and reevaluated against current education research.5,52,57

 

학생에 대한 평가를 하는 것도 유용한 방법일 수 있다.

External national or regional assessment of students may be a useful tool to consider in promoting quality assurance of medical schools. 

A uniform examination for students at the conclusion of their undergraduate medical education has been debated in a number of settings.58–60 Standardized assessment has both the advantage of providing a benchmark for achievement of all graduates and the potential to identify schools at which students are less well prepared for the next stage of their career or education. It also has the potential to stimulate the growth of educational activities that are relevant to the examination content.50,61

 

좋은 평가는 좋은 교육을 유도한다. 그러나 불행하게도, 그 반대도 마찬가지이다.

Good assessment drives good education; unfortunately, the opposite is also true.62 

A standardized examination has the potential to encourage memorization if recall of knowledge is the predominant cognitive task or to encourage the retention of outdated topics if they are still part of the examination content.55,63 It may also cause schools to de-emphasize student achievement goals that are harder to measure, such as self-directed learning or professionalism, because they may be overshadowed by the need for achievement on the tested domains. In general, if the test remains excessively static, it will discourage innovation.59,62

 

표준화 시험의 효과는 타당도, 신뢰도, 기준 설정 등이 잘 이뤄져야 나타날 것이다. 이러한 것이 잘 갖춰진다면 uniform test가 질 평가의 좋은 요소가 될 것이다.

The potential impact of standardized examinations necessitates the highest psychometric standards for validity, reliability, and standard setting in the local health care context. With caveats such as those mentioned above, a uniform test has the potential to serve as one component of an external institutional quality assessment, alongside a robust accreditation system.

 

보건의료전문직 교육의 강조

Establish health professions education as a recognized field

 

미국과 같이 의학에 대한 대중의 통제가 약했던 국가에서 '의학교육'은 교육 관련 연구를 하는 주체로서 '유기적으로' 발전해왔다. 그러나 정부가 좀 더 통제권을 갖는 국가에서는, 정부가 더 많은 교육관련 연구를 하도록 유도할 수도 있을 것이다.

A critical intermediate step in improving health professions education in Asian countries is its establishment as a recognized field.64 In the United States, where there is minimal public control of the disciplines of medicine, medical education developed organically as a growing body of education research, which led to an organizational structure of national and regional associations, medical journals, and medical school departments.20 This organic development gradually led to a broadening of criteria for promotion at many schools to include education achievements and publications.65 In more centrally controlled environments, where a government agency must be convinced of the validity of the field, authorities will be more likely to do this as more education research is produced.

 

그러나 그 반대도 사실이어서, 일단 '의학교육'이라는 분야가 확립되면 더 많은 연구가 진행될 것이다.

The inverse is also true, however; more research will be generated once the field is established. 

In Sri Lanka,66 where the field, or specialty, of medical education was recently established, faculty will now be eligible for advancement and promotion on the basis of education research, publication, and other forms of scholarship in education. This structure is likely to draw more faculty to the field and to incentivize interested faculty to publish in the domain of education research and practice. Development of the field will also promote creation of venues for the presentation of and debate about ongoing research, thus encouraging the diffusion of ideas throughout the region.39

 

교수개발을 통한 교수 부족 극복

Address faculty shortage through faculty development

 

아시아 대부분 지역에서 교육과 관련한 방법론이나 연구 부분에 대한 교수들의 능력이 상당히 부족한데, 왜냐하면 많은 교수들이 교육을 진료와 연구에 뒤따르는 부차적인 것으로 보기 때문이다.

The shortage of faculty that has resulted from a dramatic increase in the number of medical schools and that has been exacerbated by the departure of doctors and faculty members from their countries 12,33,38 may be partly alleviated by increasing the attractiveness of a career in medical education.67 Faculty skills in education methods and research are weak in most regions in Asia, because many faculty members view teaching as a secondary aspect of their responsibilities, after research and clinical work.4

 

현재 상황을 극복하기 위해서는 삼층적 접근이 필요하다. 전체 교수를 대상으로 가르치는 것, 일부 교수 그룹(subset)을 대상으로 가르치는 것, 그리고 교육의 리더를 양성하는 것이 권고된다.

To address the current situation, a trilevel approach—consisting of educating all faculty in teaching methods and skills, educating a subset of the faculty in research methods to improve quality in medical education, and developing leaders in education—is recommended.68,69 

이를 달성하기 위해서는...

This aim can be accomplished by ...

the establishment of basic educational courses at all institutes; 

the creation of advanced courses at regional centers that include research, leadership, and management issues; and 

the initiation of programs for higher educational degrees and diplomas at national centers. 

리더십과 관리능력을 갖춘 교수를 양성하는 것은 그러한 문화를 만들고 지속적 변화를 이끌어내기 위해서 필수적이다.

Faculty development in education leadership and management is essential to promote a culture that values and generates new ideas, values teamwork, and is able to implement and sustain change.67,69 

또 다른 중요한 목표는 그 지역을 아우르는 교육자들의 community를 만드는 것이다.

Another important goal of faculty development programs should be the creation throughout the region of a community of educators who can turn to each other for support and ideas.

 

중요한 첫 걸음은 현재 가지고 있는 교수개발 프로그램을 평가하여, 다양한 요구에 맞도록 개선하는 것이다. 왜냐면 역량을 강화하는 것의 효과는 학습자의 지역 맥락에 맞을 때 가장 효과적이기 때무이다. 교육에 있어서 교수개발 참여자 본국의 기관에서 진행되는 프로젝트와 연관되어야 한다. 워크숍을 이끄는 사람들은 그들이 지지하는 원칙을 만들고, 참여자들의 적극적 참여를 이끌어내야 한다. 교수들의 프로그램에 참여하도록 지원하고 교육관련 연구를 할 수 있도록 지원하는 것이 교수개발의 효과를 더욱 극대화 시킬 것이다. 국가적 수준, 지역적 수준에서 수상, fellowship 등을 수여하는 것도 문화를 만드는 좋은 방법이다.

An important first step would be to measure existing faculty development programs against this paradigm and revise them to meet the multitiered needs.70 Because capacity building works best when related to the learner's local context,71 faculty development in education should be linked to projects in participants' home institutions.67,72 Workshop leaders should also model the education principles they espouse and should encourage the active engagement of participants.70,72 Support for faculty to attend education development programs, as well as funding to support education research and capacity building in research, would bolster faculty development efforts in education. Recognition of teaching at national and regional levels through awards, fellowships, and traveling professorships is a valuable way to promote a teaching culture.

 

마지막으로 졸업후 교육의 기회가 부족한 문제도 반드시 해결되어야 한다.

Finally, the lack of opportunity for postgraduate education must be addressed. An increase in postgraduate education will help produce more faculty to fill teaching posts and will allow more physicians to stay in their home countries to complete their medical education.13

 

Conclusions

 

미국 상황과 남아시아 상황의 비교

The contexts of medicine and medical education in the United States during the period preceding the Flexner Report and in contemporary Asia are similar in some respects and different in others. An explosion of private medical education and weak government regulation define both periods. Internationalization was a factor in both settings, but with different effects. 

In the United States, there was a resultant increase in the diffusion of ideas, which contributed to a recognition of the poor state of U.S. medical education and medical practice. 

In contemporary Asia, the result has been the emigration of health workers to countries that are perceived to offer greater economic opportunity and better and more available postgraduate medical education.13 

The density of doctors in the United States was relatively high in Flexner's time; 

it is strikingly low in most of Asia today, partly because of migration. 

바로 일반화하거나 비교하기는 어려워도 두 상황 모두 비슷한 문제를 가지고 있다.

Although it is difficult to generalize and compare teaching practices, the two scenarios bear many similar deficiencies—emphasis on memorization, lack of integration of science with clinical knowledge, limited clinical experience, and weak student assessment systems.

 

위기이자 기회이다.

The recent growth of private medical schools in Asia is both an opportunity and a threat. 

These schools, which carry little historical baggage, can potentially maintain a clear focus and interest in medical students' education, and they may be capable of leading and propagating innovations across private and government medical schools.32 

Government (public) medical schools, once the dominant player in medical education in Asia, may face increasing competition from innovative private schools, many of which are highly regarded as world leaders in education.73 

However, many accrediting agencies in Asia have not lived up to their potential to improve the quality of medical education in their countries, and that failure has resulted in concerns that unplanned and poorly regulated growth may lead to lower quality.24

 

강한 인증 규제가 효과가 있을 것이라고 기대하기 어려울 수 있음.

It is difficult to anticipate whether stricter accreditation and quality assurance would force some South Asian medical schools to close, as happened in the United States after the publication of the Flexner Report,50 or whether schools would adjust to the more stringent standards and make improvements. The Flexner Report was commissioned by an agency outside of the government that was frustrated by inaction or inadequacies in the public sector 50; whether a similar review is advisable or even possible in Asia is not clear.2

플렉스너 보고서가 성공적이었던 것은, 대중의 관심이 쏠려있는 부분을 직접적으로 언급했기 때문일 수 있다. 즉 효과적인 medical care가 자신들의 삶을 바꿀 수도 있다는 것이다. 남아시아도 이러한 전략을 사용해 볼 필요가 있다.

The Flexner Report was successful, in part, because it directly addressed the concerns of the public, which understood for the first time that effective medical care by competent physicians could make a difference in their lives.50 To garner support from the public and the relevant government entities in South Asia, the strategy of the Flexner Report should be followed. Recommendations for improving medical education in contemporary Asia should be made in the context of improving the health of the population.

 

정치적, 사회적, 문화적, 행정적 요인들을 잘 고려해야 한다.

Complexities surrounding the change process necessitate careful consideration of political, social, cultural, and administrative factors.74,75 

Experience in Asia suggests 76 that the success of any changes depends on collaboration with key stakeholders and constituencies and on the judicious selection of high-priority areas for improvements that are less likely to face resistance.50 Examples of such areas are creating faculty development opportunities, promoting active learning, and recognizing medical education as an established field of scholarship. High-priority but high-resistance areas of improvement might be centered on the more contentious issues, such as criteria for admission and standardized regional examinations. Diversified promotion of change at individual, institutional, and national levels may also increase the overall likelihood of success. Advocates for change in each country need to think strategically and to start with innovations that have a higher chance of success.76

 

플렉스너 보고서가 현재 아시아 의학교육에 갖는 의미는 상당하다.

The relevance of Flexner's recommendations to the current status of medical education in Asia is striking, in terms of both the progressive nature of his thinking in 1910 and the need to improve medical education in Asia today.77,78 The improvements in U.S. medical education that began before the Flexner Report's release and that followed it had a profound effect on medical education on several continents.50 Given the movement of physicians around the world, particularly the export of physicians from Asia to the West, improvement in medical education in South Asia also will have a global impact.

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Acad Med. 2010 Feb;85(2):333-9. doi: 10.1097/ACM.0b013e3181c874cb.

Relevance of the Flexner Report to contemporary medical education in South Asia.

Amin Z1, Burdick WP, Supe A, Singh T.

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Abstract

A century after the publication of Medical Education in the United States and Canada: A Report to the Carnegie Foundation for the Advancement of Teaching (the Flexner Report), the quality of medical education in much of Asia is threatened by weak regulation, inadequate public funding, and explosive growth of private medical schools. Competition for students' fees and an ineffectual accreditation process have resulted in questionable admission practices, stagnant curricula, antiquated learning methods, and dubious assessment practices. The authors' purpose is to explore therelevance of Flexner's observations, as detailed in his report, to contemporary medical education in South Asia, to analyze the consequences of growth, and to recommend pragmatic changes. Major drivers for growth are the supply-demand mismatch for medical school positions, weak governmental regulation, private sector participation, and corruption. The consequences are urban-centric growth, shortage of qualified faculty, commercialization of postgraduate education, untenable assessment practices, emphasis on rote learning, and inadequate clinical exposure. Recommendations include strengthening accreditation standards and processes possibly by introducing regional or national student assessment, developing defensible student assessment systems, recognizing health profession education as a field of scholarship, and creating a tiered approach to faculty development in education. The relevance of Flexner's recommendations to the current status of medical education in South Asia is striking, in terms of both the progressive nature of his thinking in 1910 and the need to improve medical education in Asia today. In a highly connected world, the improvement of Asian medical education will have a global impact.

Comment in

• The Flexner Report and contemporary medical education in South Asia: an exception. [Acad Med. 2011]