의학교육에서 국제보건 : 교육과 기회 증가필요

Global Health in Medical Education: A Call for More Training and Opportunities

Paul K. Drain, MPH, Aron Primack, MD, MA, D. Dan Hunt, MD, MBA,

Wafaie W. Fawzi, MB, DrPH, King K. Holmes, MD, PhD, and Pierce Gardner, MD

세계는 점차 서로 연결되어가고 있고, 국제화는 거의 모든 사람의 생활에 영향을 미치고 있다. 국가와 대륙간의 사람, 생산품, 서비스, 정보의 교환이 전 세계의 보건과 보건의료전달에 엄청난 영향을 주고 있다. 국제적인 인구의 이동과 생산품의 분포로 인해 HIV/AIDS, SARS와 같은 communicable disease의 위협이 더 커지고 있고, 조류독감, 다제내성 미생물 등의 위협도 커지고 있다. 이제 지구 한 부분의 공공보건의 문제는 전 세계의 문제라고 할 수 있다.

The world has become increasingly interconnected and globalization now affects virtually every person’s life. Increases in the flow of people, products, services, and information between and among countries and continents are having a dramatic influence on the world’s health and health care delivery.1 The global migration of people and the distribution of products increases the threat of communicable diseases, such as HIV/AIDS and SARS, as well as the rapid spread of avian influenza and multidrug-resistant microorganisms.2,3 In today’s society, the emergence of a new public health threat in one part of the world becomes a concern throughout the world.2

개발도상국에서 진행된 연구가 선진국 의료 문제와 관련된 많은 문제에 대한 답을 주는 경우도 많다. 그러나 현재 연구에 투입되는 자본은 상당히 고소득 국가에 치우쳐있으며, 중-저소득 국가의 질병에 대한 연구에는 많은 투자가 되고 있지 않다. 부상, 환경과 관련한 건강문제 등이 개발도상국에서 지속적으로 문제가 되고 있고, 다른 한편으로는 만성 noncommunicable disease는 계속 늘어나고 있어서 이들 지역의 열악한 건강상태에 대한 맥락-기반 이해가 필요한 상황이다. 또한 UN의 MDG를 달성하기 위해서 저소득국가의 연구역량을 어떻게 향상시킬 수 있을지, 공공과 민간의 협력을 유지할 수 있을지, 평등과 성 문제를 어떻게 통합할 수 있을지 등에 대한 연구 노력이 계속되고 있다.

Research conducted in resource-poor settings has helped answer many questions relevant to medical care in developed countries, but current research funding disproportionately favors studying the diseases of high-income countries over studying those diseases more prevalent in low- and middle-income countries.4 Whereas injury and environmental health problems are persistent concerns in resource-poor settings and chronic noncommunicable diseases are continuing to rise, further efforts are needed to understand the contextual basis for poor health among these communities.5,6 To address the United Nations’ Millennium Development Goals, research efforts are being specifically directed to better understand how to strengthen research capacity in low-income countries, sustain the emerging public–private partnerships, and integrate equity and gender issues.7,8

Increases in the capacity and exchange of health services and information can be used to better address global health threats and influence research priorities.5,9 Medicine and public health must continue to become more globalized so that by addressing the emergence and distribution of diseases in low- and middle-income countries, the health of communities in high-income countries is promoted as well. 

Global health needs에 부응한다면...다음과 같은 것에 도움이 될 것이다.

• 경제 개발
• 건강 불평등 해소
• 정치적 안정성 유도
• 안전(security)유도

이것이 최근 Institute of Medicine이 미국으로 하여금 개발도상국에 HIV문제를 해결하기 위한 보건의료인력을 파견(mobilize)하는 조직을 만들 것을 요구한 이유이기도 하다.

In addition, addressing global health needs, especially among poorer countries, will not only help promote economic development but may also reduce health inequalities and foster political stability and security.10–13 These were some of the reasons the Institute of Medicine recently called on the federal government to create an organization to mobilize U.S. health care workers in the fight against HIV in developing countries.14

 

새로 양성되는 의사에 대한 국제보건 수요

Global Health Demands on New Physicians

 

세계화가 진행되고 있는 이 시점에, 의사들은 다음의 주제 등에 대한 더 넓은 이해가 필요하다.

In the era of globalization, physicians are now expected to have a broader understanding of various alternative and culturally determined medical practices, as well as knowledge of tropical diseases and emerging global infections.15 

여행과 이주가 많아지면서 travel medicine에 대한 수요도 많아졌다. 따라서 의사들은 다음과 같은 능력이 있어야 한다.

The steady increase of travel and migration has increased clinical visits for travel medicine, including immigrants visiting their home country.16,17 

• Hence, a clinician’s ability to recognize or suspect presentations of diseases endemic to other world regions has become increasingly important.18 
• Physicians must also learn about determinants of health and disease, including socioeconomic, environmental, and political factors, which are becoming more globally interconnected.15 
• New physicians will also be facing more cross-cultural interactions and must be comfortable working with translators and understanding cultural beliefs among different ethnic groups.18 

치유(Healing)에 대한 서로 다른 문화적 접근의 차이는 ethnomedicine 분야에 잘 정리되어 있다.

The complexity of the interplay between different cultural approaches to healing has been well documented in the field of ethnomedicine 19 as well as in the popular book The Spirit Catches You and You Fall Down.20 

또한 선진국에서 의사들은 의료적으로 취약한 사람, 보험이 없는 사람들의 요구에도 맞춰줄 수 있어야 한다.

Furthermore, in developed countries, primary care physicians must meet the needs of the medically underserved and uninsured, who suffer increased disease morbidity 21 and whose needs could be better addressed if health care professionals had a better understanding of global health. 

요약하자면, 새롭게 양성되는 의사는 국제보건이슈에 익숙해져 있어야 하고, 기존의/새롭게 등장할 질병을 이해해야 하고, 다양한 문화에 대한 이해와 감수성을 가지고 있어야 한다.

In summary, newly trained physicians need to be well rounded on global health issues, understand existing and newly emerging global diseases, and be cross-culturally competent and sensitive.

 

의과대학에서의 국제보건 교육

Education for Global Health in Medical Schools

 

미국의 의과대학생들은 50년 이상 개발도상국에서의 임상실습에 참여해왔고, 최근에 그와 관련된 흥미와 참여가 더 많아지고 있다.

Medical students in the United States have engaged in international rotations in developing countries for over half a century,22 and their interest and participation has accelerated in recent years.23 

In 1978, 5.9% of graduating American medical students had completed a clinical education experience abroad as part of their medical education (Figure 1).23
By 2004, 22.3% of graduating American medical students had participated in an international health experience.24 

그러나 효과를 최대한으로 끌어올리기 위해서는 이러한 해외 임상실습이 이에 대한 교육과정과 포괄적으로 통합되어야 한다. 의과대학생들은 international clinical rotation and research opportunities를 위해서 많은 시간을 투자하고 있으며, 의과대학생은 국제보건 문제를 좀 더 강조할 것에 대한 요구를 이끌어나가고 있다.

However, for maximal effect, international clinical rotations need to be integrated with a comprehensive international health curriculum.25 In 1991, only 22% of U.S. medical schools offered a course on international health.26 In addition, many medical students are now expanding the time they spend in medical school to pursue international clinical rotations and research opportunities. Medical students have been leading much of the call for greater emphasis on global health issues as part of medical education.

현재 거의 모든 대학이 의과대학생들이 국제보건에 대해 흥미를 갖고 활동할 수 있는 것을 마련해주고 있다.

Currently, almost all medical schools have some avenues for medical students to pursue global health interests or activities (P. Gardner, personal observation, 2006). 

• At a minimal level, the great majority of medical schools have a student-led interest group to discuss various global health topics, often with faculty or visiting lecturers. 
• Some schools are now requiring first-year students to choose an area of special interest and are offering global health as an option, which is proving to be highly popular. 
• At medical schools with more mature global health programs, travel support is generally available to help medical students participate in global health projects. 
• Furthermore, many of these schools and their affiliated hospitals have formed partnerships with foreign institutions, and some schools have funding for bidirectional exchange programs. 
• Finally, a number of medical schools have created specific departments of global health, often in partnership with a school of public health, and now have more fully developed global health programs. 

In the past year, medical schools at Vanderbilt University, Harvard University, and Duke University, to name a few, have launched or expanded major initiatives in global health. The University of Washington was recently awarded $30 million by the Bill and Melinda Gates Foundation to support the creation of a department of global health.27 Thus, global health is increasingly being recognized as important by medical schools, and the growing interest among medical students continues to push global health into the mainstream of medical education.

 

International clinical rotation의 장점

The Benefits of International Clinical Rotations

의과대학생들은 international clinical rotation뿐만 아니라 의과대학 교육과정에 이런 내용을 포함시키는 것의 장점을 잘 인지하고 있다.

Medical students recognize the benefits of including global health topics in the medical curriculum, as well as international clinical rotations in the training of medical students.15,28 

• Those who have completed a rotation in a developing country have reported increased skills and confidence, enhanced sensitivity to cost issues, less reliance on technology, and greater appreciation for cross-cultural communication.22,28 
• They become better clinicians by broadening their clinical exposure and experience, most obviously with regard to diseases that are endemic in developing countries and rarely encountered in the student’s home country. 
• They also learn to practice medicine with limited access to laboratory tests and expensive diagnostic procedures, relying on strengthened physical examination skills and depending less on laboratory values, radiologic imaging, and other diagnostic testing, and they develop a deeper appreciation for global public health issues and become more culturally sensitive.22,28,29 
• For instance, in-depth interviews with 24 Dutch medical students who completed an international clinical rotation revealed meaningful learning experiences in the domains of medical knowledge, clinical skills, international health care organization, international medical education, society and culture, and personal growth.30 
• International rotations provide not only training but also opportunities for service, which can be both personally rewarding and useful for building partnerships. 

요약하면, international clinical rotation을 마친 학생들은 질병 양상을 더 잘 파악하고, 더 포괄적으로 임상술기 기술을 발전시킬 수 있으며, 우수한 문화적 민감성을 바탕으로 환자에게 접근할 수 있다. 이것이 모두 더 나은 의사를 만드는 특징이다.

In summary, medical students who have completed an international clinical rotation may learn to more readily recognize disease presentations, develop more comprehensive physical exam skills, and approach patients with greater cultural sensitivity—all attributes that make for becoming better clinicians.

 

International Clinical Rotation은 학생에게만 도움이 되는 것이 아니라, 보건의료시스템의 요구에도 도움이 된다.

International clinical rotations not only benefit the medical student, but also help to serve the needs of the health care system. 

• Medical students and residents with international clinical experience are more likely to enter general primary care medicine.22,31–34 
• Further, medical students and residents with international experience are more likely to obtain a public health degree and engage in community service.31,32 
• Similarly, they embrace attitudes and desires to practice medicine among underserved and multicultural populations.31–35 
• A two-year follow-up survey found that 23% of medical students who participated in an international clinical elective intended to work in resource-poor settings, compared with only 6% of medical students with similar plans who did not participate in an international clinical elective.36 
• A follow-up survey of American fourth-year medical students who had completed a clinical rotation abroad found that a six-week intensive experience in a developing country influenced the medical careers of 67% of the participants; 74% were engaged in primary care specialties, and 60% planned on working overseas in the future.32 

요약하면, International Clinical Rotation은 의대생들로 하여금 나중에 일차의료현장에 참여하게 하고, 공공보건 학위를 취득하는데 영향을 주고, 가난한 그리고 소수인종을 위해 의학을 펼칠 수 있게 영향을 준다.

In summary, international clinical rotations influence medical students to enter primary care medicine, obtain public health degrees, and practice medicine among the poor and ethnic minorities.

 

의과대학생들에게 주어진 현재의 기회

Current Opportunities for Medical Students

 

몇 가지 프로그램이 있지만, 더 일찍 경험할수록 진로에 영향을 줄 가능성도 더 커진다. 일부 의과대학은 의과대학생들에게 국제보건 관련 진로를 추구할 수 있도록 프로그램을 만들었다.

Although several residency programs have long offered international electives,31,34,37 earlier experiences could have an even greater impact on shaping career decisions in medicine. A few medical schools have created programs specifically to train medical students for careers in global health. 

• In 1998, Ben-Gurion University and Columbia University founded a medical curriculum in Israel with the purpose of training physicians in global health and medicine.38 
• More recently, the Royal Free and University College Medical School in the United Kingdom created an intercalated bachelor of science degree (equivalent to an expanded fifth year of a U.S. medical school) in international health.39

또한 교과목이나 세미나를 개설한 학교도 많고, international ratation의 arrange를 도와주는 학교도 있다.

Many medical schools do offer a course or seminar on global health, and several now provide opportunities or help arrange international rotations. 

• The Karolinska Institute in Sweden offers students an optional five-week full-time course on global health.40 
• The University of Arizona has an international health option that allows medical students to conduct international fieldwork during their last year of clinical training.41 
• The University of Washington recently introduced a global health pathway, which includes course work on global health and tropical medicine as well as fully funded international clinical rotations during the last year of medical school.42 
• The University of Massachusetts offers a Global Multiculturalism Track to improve cultural competency for medical students working with local immigrants.43 
• Several other medical schools that offer global health teaching or international clinical opportunities can be found at the Global Health Education Consortium 44 and the American Medical Student Association 45 Web sites.

몇몇 협회, 기관, 조직 등에서는 장학금이나 펠로우십을 제공한다.

Several associations, organizations, and institutions have recently created scholarships and fellowships for medical students to pursue international research and training. 

• The Global Health Education Consortium created the Carole M. Davis Scholarship to assist medical students to complete fieldwork abroad.46 
• The American Society of Tropical Medicine and Hygiene established the Benjamin H. Kean Traveling Fellowship to fund medical students, residents, and fellows for an international tropical medicine elective.47 
• The National Institutes of Health’s (NIH) Fogarty International Center (FIC) and the Ellison Medical Foundation have established the Fogarty/Ellison Overseas Fellowships in Global Health and Clinical Research Training, which allow medical students to spend 10 months with an established NIH-supported research center in a low- or middle-income country.48 
• In 2005–2006, this fellowship allowed 27 U.S. fellowship recipients and 27 matching fellows from the foreign sites to work in 18 research centers around the world. To our knowledge, this is the only one-year fellowship that supports American medical students for a year of clinical research training in a developing country. 
• In addition, the FIC’s newly established Framework Programs for Global Health provides support for NIH-funded U.S. and foreign institutions to help develop multidisciplinary curricula in global health and encourages faculty and students from diverse disciplines, including business, law, journalism, and engineering, to work collaboratively with traditional partners in global health research.

 

의과대학생들의 관점

The Perspectives of Medical Students

의과대학생들이나 레지던트는 더 많은 국제보건 교육과 international rotation기회를 요구하고 있다. 이런 기회를 경험한 거의 대부분의 의대생들은 경험이 더 풍부해졌고, 자신이 받은 교육에서 최고의 경험이었다고 말하고 있다.

Medical students and residents are calling for more global health teaching and international rotation opportunities during their medical school education.34,49 Nearly all medical students who have had international rotations report that these rotations are enriching experiences, and many consider them the best part of their medical education.50,51 

• In a survey of University of Arizona medical students who completed an international clinical rotation, all 133 participants indicated that they would recommend the program to their peers.41 
• In a more recent survey, 58 of 60 American medical students who completed six to eight weeks of field experience in a developing country said they would recommend an international clinical rotation to their peers.28 
• A survey of Yale University internal medicine residents found that 60% of those who had completed an international clinical rotation, as well as 45% of those who had not completed an international rotation, felt that medical school training should include exposure to health care in developing countries.34 

이러한 국제보건에 대한 관심 증가를 반영하여, 이제 지원자들은 의과대학이나 레지던트 프로그램을 선택할 때 국제보건 훈련 프로그램이나 그러한 기회를 기준으로 고를 수도 있다.

As a reflection of the growing interest in global health, applicants may now choose medical schools and residency programs on the basis of global health training programs and opportunities.

 

국제보건 교육에 관한 제안

Suggestions for Developing Global Health Education

미국의 의과대학 시스템은 점점 의대생과 젊은 의사들이 국제보건 방향의 진로를 추구할 것을 권장하고 지원하고 있다. 더 많은 연구를 통해서 international clinical rotation의 효과를 좀 더 명확히 할 수도 있음에도 불구하고, 그 이점에 대한 인식은 그다지 나아지고 있지 않다. 몇 가지 제안을 하고자 한다.

The U.S. medical system has been called upon to encourage and assist more medical students and young physicians to enter global health careers.14,52 Further structured research could better elucidate the range of effects of international clinical rotations among medical students, including costs, which may include variability in medical supervision, personal safety and liability concerns, and time away from family. However, recognition of the benefits has been rather consistent. Although opportunities could be provided for students to work more with local multicultural populations, these experiences have only some, and not all, of the benefits of working in international, resource-poor settings. We now suggest several steps that can be taken by medical schools to meet the growing interest and demands of medical students for more training and opportunities in global health (List 1).

첫 단계로서 교육과정에 국제보건 주제를 통합해야 한다.

As a first step, medical schools could integrate global health topics into core medical curricula. 

• In addition to teaching about tropical diseases and providing cross-cultural training, medical schools could also offer courses on international public health, medical anthropology, and global health economics. 
• This could be facilitated by fostering relationships with other schools, particularly schools of public health, because medicine and public health are largely intertwined in developing countries. 
• Additionally, schools could establish a global health pathway or track to encourage and recognize students gaining global health training and international clinical experiences. 
• Finally, students pursuing combined degrees, such as MD/PhD and MD/MPH programs, could be encouraged to concentrate on global health.

임상실습 기간동안에 international elective를 할 수 있도록 행정적/재정적/시간적 기회가 주어져야 한다.

Medical students could be provided with adequate administrative and financial support, opportunities, and time to conduct an international elective during the clinical years. 

• 기회가 제한되어 있음 : 
• Currently, the limited number of opportunities and difficulty in arranging an international rotation discourage medical students from expanding their clinical experience. 
• 안전 확보를 위한 적절한 조직과 감독기구가 필요함 : 
• International clinical electives will require adequate organization and supervision to maintain safety for medical students and to avoid the danger of students practicing beyond their medical competence.30 
• logistic support등의 행정지원 필요 : 
• Medical schools can better serve students by establishing an administrative position or office to provide logistic support to facilitate international rotations. 
• 전형적인 / 적정 기간은 6~8주 정도. 연구 프로그램은 더 많은 시간 필요 : 
• The typical, and perhaps the optimum, amount of time for a clinical rotation is six to eight weeks, depending in part on pretravel logistic support. An international research rotation typically requires more time than traditional rotations for both the research program and the medical student to reap the full benefit, and would be highly dependent on the research being conducted. 
• 개발도상국 기관/학교와 파트너십 필요 : 
• Medical schools and hospitals in developed countries could initiate more direct collaborative partnerships with medical institutions in developing countries to foster innovative, long-term partnerships for an exchange of resources and training opportunities.14,53 Pairing medical schools and hospitals and promoting such an exchange will lead to more qualified physicians and to improved health care delivery at both institutions. 
• 그 지역의 멘토/감독이 필요 : 
• Traveling medical students will need knowledgeable onsite mentors and a close relationship with a faculty supervisor, should they need assistance. 
• 개발도상국의 기관들도 혜택을 볼 것임 : 
• Medical institutions in developing countries will benefit by having greater access to medical information, visiting lecturers, material resources, and additional training opportunities. 
• 항공료 등의 지원 필요 : 
• Medical schools could also assist students in accessing available scholarships for travel costs, because limited financial resources will continue to hinder medical students from being able to participate in international rotations.

마지막으로, 더 많은 학생이 이러한 기회를 얻고, 일상화되기를 바란다. 이러한 기회가 제한되있고, 산발적으로 제공된다면 소규모의, 일부 선택된 학생만이 그러한 기회를 얻을 수 있을 것이다. 그리고 소수자 학생들에게는 이러한 기회가 돌아가지 않을 것이다. 

Finally, we recommend that all medical students receive training in global health and that an international clinical rotation become more routinely available to medical students. If international clinical electives opportunities remain limited and sparse, then programs will be likely to continue to draw on a small, self-selected group of students who are internationally oriented and well traveled,54 and opportunities will likely not reach those students, including members of U.S. minority groups, who would most greatly benefit from an international rotation.30 The benefits to medical students are more than sufficient to justify promoting an international clinical rotation as a worthy training opportunity.

 

Conclusion

 

Thus far, medical schools have been slow in responding to the global health interests of their students. Medical schools should be encouraged to continue integrating global health teaching into medical curricula while creating and promoting more opportunities for international rotations. Also, they should move toward making an international clinical rotation a routine part of medical education. At the same time, more quantitative data on global health in medical education should be collected. Teaching the global aspects of medicine and understanding medical resources and care in a developing country will prepare future physicians to have a more complete understanding of health and medicine and will encourage them to pursue primary care specialties and to serve in resource-poor settings. This, in turn, will strengthen our health care system.

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Acad Med. 2007 Mar;82(3):226-30.

Global health in medical education: a call for more training and opportunities.

Drain PK1, Primack A, Hunt DD, Fawzi WW, Holmes KK, Gardner P.

Author information

Abstract

Worldwide increases in global migration and trade have been making communicable diseases a concern throughout the world and have highlighted the connections in health and medicine among and between continents. Physicians in developed countries are now expected to have a broader knowledge of tropical disease and newly emerging infections, while being culturally sensitive to the increasing number of international travelers and ethnic minority populations. Exposing medical students to these global health issues encourages students to enter primary care medicine, obtain public health degrees, and practice medicine among the poor and ethnic minorities. In addition, medical students who have completed an international clinical rotation often report a greater ability to recognize disease presentations, more comprehensive physical exam skills with less reliance on expensive imaging, and greater cultural sensitivity. American medical students have become increasingly more interested and active in global health, but medical schools have been slow to respond. The authors review the evidence supporting the benefits of promoting more global health teaching and opportunities among medical students. Finally, the authors suggest several steps that medical schools can take to meet the growing global health interest of medical students, which will make them better physicians and strengthen our medical system.

Comment in

• Bring global health and global medicine home. [Acad Med. 2013]
• Bring global health and global medicine home--in reply to Ventres and Page and to Asgary. [Acad Med. 2013]
• Bring global health and global medicine home. [Acad Med. 2013]

PMID:

 

17327707

 

[PubMed - indexed for MEDLINE]