3년제 의과대학의 장점과 과제: 근거 중심 토론 (Acad Med, 2015)

3년제 의과대학의 장점과 과제: 근거 중심 토론 (Acad Med, 2015)

The Merits and Challenges of Three-Year Medical School Curricula: Time for an Evidence-Based Discussion

John R. Raymond Sr, MD, Joseph E. Kerschner, MD, William J. Hueston, MD, and Cheryl A. Maurana, PhD

최근의 3년제 의과대학에 대한 관심은 2025년까지 46,000명에서 90,000명의 의사가 부족할 수도 있다는 예상과, 의과대학생들의 빚이 점차 늘어나고 있다는 것으로부터 촉발되었다. 3년제 의과대학 프로그램은 여러 논문과 언론에서 논쟁이 되온 바 있다.

The recent resurgence of interest in three-year medical school curricula has been driven by a projected shortage of 46,000 to 90,000 physicians by 20251,2 and by mounting medical student debt. Three-year programs have been the subject of spirited debate in the peer-reviewed medical literature,3–7 the mainstream press,8–10 and online publications.11

앞서 이야기된 바와 같이 의사가 부족할 것이라는 예측과 의과대학생의 빚이 늘어나고 있다는 주요한 이유 외에도, 일부 레지던트 프로그램 디렉터과 일부 의학교육 리더들은 현재와 같은 의과대학 교육 구조에서 4학년의 가치가 무엇인가에 대한 의구심을 표한다. 실제로 1990년 Robert Petersdorf는 "현재의 4학년은 세계 각 국을 여행다니는 기회이거나 임상실습을 구실로 한 오디션에 불과하지 않는다"라고 지적했다. 더 최근에는 AOA와 AACOM의 blue-ribbon commission은 "정해진 몇 달을 채워야 하는 교육이 아니라 역량을 성취하는 것에 기반한 새로운 교육 모델이 필요하다"라고 권고했다. 

In addition to citing the growing education debt burden and projected physician shortages as primary reasons to support three-year medical school curricula, proponents note that some residency program directors12 and some medical education leaders have questioned the value of the fourth year of medical school as currently structured. Indeed, in 1990 Robert Petersdorf,13 then president of the Association of American Medical Colleges, commented that “the present fourth year … turns out to be nothing more than a chance to travel about the country or to engage in audition clerkships.” More recently, a blue-ribbon commission of the American Osteopathic Association and the American Association of Colleges of Osteopathic Medicine recommended creation of “a new education model that is based on achievement of competencies without a prescribed number of months of study.”14

3년제 교육과정에 대해 우려를 표하는 사람들은 다음과 같은 것을 걱정한다.

Individuals concerned about three-year curricula cite potential problems such as 

• student burnout, 
• faculty fatigue, 
• the increasing complexity of medicine, 
• quality issues, and 
• diminished competitiveness for residencies.15–18

간결성을 위해서 우리는 3년제- 4년제- 모델이라고 지칭하지만, 이 둘 사이의 교육기간 차이는 몇 주 혹은 몇 달 정도이며, 이는 3년제 교육에서는 방학이 상당히 줄어들거나 없어지기 때문이다. LCME는 미국과 캐나다의 MD program이 최소 130주 이상일 것을 요구하나 그 130주의 교육이 제공되는 총 기간에 대해 명시하고 있지는 않다. 이러한 관점에서 3년제 교육과정은 압축되거나/변형되거나/전공의 과정과 통합된 것이라 볼 수 있다.

For brevity, we refer to three- and four- year models, but it is critical to note that the actual differences in contact hours between these types of curricula are measured in weeks or months because of the elimination of summers off and the shortening of vacations and intercessions in typical three-year curricula. The Liaison Committee on Medical Education requires accredited U.S. and Canadian MD-granting programs to include a minimum of 130 weeks of curriculum but does not mandate a time frame over which the curriculum must be delivered.19 For the purposes of this Perspective, therefore, “three-year programs” refers to programs that have been compressed, modified, or integrated with residency training to achieve a three- year medical school graduation goal.

문헌에서 나타난 3년제 교육과정

Three-Year Medical Curricula in the Literature

3년제 교육과정은 새로운 아이디어가 아니다. 여러 문헌에서 1970년대와 1980년대에 미국에는 3년제 교육과정이 여럿 있었으며, 두 개의 캐나다 의과대학은 40년 이상 그러한 프로그램을 운영하고 있다. 이들은 가정의학이나 내과학 전공의 과정을 합하여 3+3 과정으로 운영하면서, 의과대학 4학년을 전공의 1년차로 병합하였으며, 이러한 3년제 프로그램의 학생들이 4년제 프로그램 학생들과 거의 모든 단계에서 비슷한 수행능력을 보여준다는 것을 제시했다.

The three-year medical school curriculum is not a new idea.17,20,21 The broad array of published works—from U.S. medical schools that had three-year programs in the 1970s and 1980s, from two Canadian medical schools with more than four decades of experience with such programs, and from family medicine and internal medicine 3 + 3 programs, which allow medical students to accelerate their medical education by combining their fourth year of medical school with their first year of residency—suggests that students in three-year programs perform as well as their four-year counterparts at all stages of their careers.

1970년대와 1980년대의 미국 의과대학

U.S. medical school experiences in the 1970s–1980s

전통적인 플렉스너의 의학교육 모델은 약 100년간 거의 그대로 자리를 지켜왔고 2년의 전임상실습 교육과 2년의 임상실습 교육으로 구성되었다. 아브라함 플렉스너가 이 모델을 권고할 때는 의과대학 교육과정이 의사 수련의 거의 전부였다. 즉, 전공의 교육을 할 수 있는 프로그램이 거의 없었다. 그러나 오늘날 의사 양성 과정은 3~4년이 아니라 7년에서 10년까지 걸린다.

The traditional Flexnerian model of medical education has remained largely unchanged for more than a century, with students sequentially mastering two years of preclinical classes followed by two years of clinical clerkships.22 When Abraham Flexner recommended this model, medical school was the extent of most physicians’ training—there was little availability of residency training programs. Today, however, becoming a physician is not a three- or four-year proposition but, rather, a 7- to 10-year journey with medical school comprising the first step.

미국에서 4년제 의과대학 모델은 제2차 세계대전 동안 변형되어 3년도 안되는 기간에 의사를 양성했었다. 또한 4년제 모델은 1970년대에 향후 의사가 부족해질 것이라는 예상에 따라 3년제 교육과정이 도입되었으며, 이는 1971년의 CHMTA에 의해서 더욱 촉발되었다. 1973년, 미국 의과대학의 거의 25%에서 3년제 프로그램을 운영하였고, 1973~1974년에는 입학정원이 2600명에 달했다.

In the United States, the four-year model was modified out of necessity during World War II, when physicians were trained in less than three years.23,24 The four-year model also was challenged in the 1970s when three-year curricula were created in response to a perceived physician shortage and were fueled by the availability of federal capitation funding through the Comprehensive Health Manpower Training Act of 1971 (Public Law 92-157). In 1973, nearly 25% of U.S. medical schools offered three-year programs,7,25 with enrollment in these programs peaking at about 2,600 students in 1973–1974.24

그러나 이러한 3년제 프로그램은 빠르게 소멸되어 결국 사라지게 되었는데, 이는 재정 지원이 중단되었을 뿐 아니라, 의사 부족에 대한 우려도 점차 줄었고, 이러한 3년제 교육과정의 속도와 강도에 교수들이 전반적으로 불만을 품었기 때문이다. 그러나 학생들은 대체로 만족해왔다. 또한 3년제든 4년제든 대부분의 연구 결과에서는 그 졸업생들의 수준에 별다른 차이가 없다는 것도 눈여겨 볼 만하다.

These three-year programs waned rapidly, however, and eventually disappeared. Their demise was due to the discontinuation of capitation funding, declining concern about physician shortages, and broad-based faculty dissatisfaction with the pace and intensity of such programs.15,18,24 Students, however, generally were satisfied with their experiences.25 It is noteworthy that, despite faculty concerns, most studies showed no significant differences in the academic or clinical performances of the graduates of three-year and four-year programs.26–30

대부분의 근거들은 학생들이 3년에 의학교육과정을 마스터할 수 있음을 지지한다.

More contemporary evidence suggests that students can master the medical school curriculum in three years.

듀크 의과대학의 예, 유펜 의과대학의 예, 하버드 의과대학의 예

• At Duke University School of Medicine, for example, students focus on the basic sciences in the first year, complete their core clerkships in the second year, and devote the third and fourth years to electives and research.31 
• At the Perelman School of Medicine at the University of Pennsylvania, the fourth year includes 36 weeks of flexible time and scholarly training.32 
• Harvard Medical School’s New Integrated Curriculum carves out nearly a year for advanced experiences in clinical medicine and basic science, a scholarly capstone project, electives, and a subinternship.33

캐나다 의과대학의 경험

Canadian medical school experiences

맥마스터의 the Michael G. DeGroote School of Medicine , 캘거리의 the Cumming School of Medicine. 두 학교는 임상경험에 초점을 둔 역량바탕 교육과정(각각 130주, 131주)을 운영함.

In Canada, the Michael G. DeGroote School of Medicine at McMaster University (McMaster) and the Cumming School of Medicine at the University of Calgary (Calgary) have experience with three-year curricula that spans more than four decades. The McMaster and Calgary three-year programs deliver their competency-based curricula focused on clinical experience and learning in context in 130 weeks and 131 weeks, respectively.

캘거리 의과대학의 졸업생과 앨버타 의과대학(4년제)의 졸업생 비교 (만족도도 높고, 역량도 뛰어나다)

A comparison of medical school graduates of Calgary and the University of Alberta (which has a four-year curriculum) showed Calgary graduates’ satisfaction levels to be comparable to or higher than those of Alberta graduates regarding their training, practice patterns, specialty choices, and maintenance of competence in clinical practice.34 Additionally, Calgary graduates have been rated as superior or equivalent to graduates of four-year Canadian medical schools in various domains of competency, using data from the College of Physicians and Surgeons of Alberta’s Physician Achievement Review program.35,36

Neufeld 등은 맥마스터 의과대학의 경험을 고찰하면서 졸업생이 우수함을 보여주었음.

Neufeld and colleagues37 reviewed the McMaster experience through 1989. They found that McMaster graduates were comparable to four-year graduates of U.S. and Canadian medical schools in terms of 

• performance on standardized national examinations, 
• preparation for and performance during residency, 
• ability to obtain preferred first-year residencies, and 
• percentage pursuing primary care. 

Interestingly, they also found that McMaster graduates were more likely 

• to pursue academic careers compared with graduates of four-year medical schools. 
• A survey of faculty attitudes at McMaster regarding the three-year curriculum demonstrated satisfaction.38

가정의학, 내과학 연계 프로그램 

Accelerated family medicine and internal medicine program experiences

1980년대와 1990년대에 약 25개의 미국 의과대학이 의과대학 4학년 대신 가정의학 전공의 과정과 연계한 3+3 프로그램을 운영하였다. 그러나 GME 인정 이슈때문에 결국 사라졌다.

In the 1980s and 1990s, approximately 25 U.S. medical schools offered accelerated family medicine programs that allowed students to begin residency training while finishing their fourth year of medical school. These 3 + 3 programs eventually were terminated because of unresolved graduate medical education (GME) accreditation issues.

연구를 살펴보면 이러한 과정의 학생이 4년제 학생에 뒤지지 않는다.

Studies39–43 showed performance of students in these programs to be comparable to that of students in traditional four-year curricula

New York Medical College and St. Vincent’s Catholic Medical Centers of New York 의 비교연구

A study of such a curriculum at New York Medical College and St. Vincent’s Catholic Medical Centers of New York compared six classes of residents who had completed internal medicine training from 1995 to 2000. Graduates of the accelerated program were comparable to graduates of the traditional program

따라서 가정의학과 내과 연계 프로그램은 수행능력을 손실시키지 않고도 수련 기간을 단축하는 효과가 있다. 

Thus, accelerated family medicine and internal medicine programs have been shown to reduce training time without degradation of performance. Although not directly comparable, students in six-year baccalaureate–MD programs have been found to perform as well as traditional students on board examinations.46

미국에서 등장하고 있는 3년제 교육 프로그램

Emerging Three-Year Medical School Programs in the United States

다양한 3년제 모델이 등장하고 있다.

A rich variety of three-year medical school curriculum models is emerging in the United States (Figure 1). 

이 모든 프로그램들은 일정부분 역량바탕 평가를 하고 있다.

All of them focus to some degree on competency- based assessment and advancement of students.

• Lake Erie College of Osteopathic Medicine (LECOM) in 2007 initiated the Primary Care Scholars Pathway (PCSP), a three-year curriculum for students committing to family medicine. (...) In 2011, LECOM began the Accelerated Physician Assistant Pathway (APAP), a customized three-year medical school track for practicing physician assistants.
• Columbia University College of Physicians and Surgeons in 2013 began a three-year Fast-Track MD program, which admits up to four students holding life science PhDs each year.51
• Mercer University School of Medicine in 2010 initiated the Accelerated Track in Family Medicine on its Savannah campus.
• Texas Tech University Health Sciences Center began its Family Medicine Accelerated Track (FMAT) in 2011.
• The New York University (NYU) School of Medicine began a three- year track in 2013.
• The University of California Davis School of Medicine, in partnership with Kaiser Permanente Northern California, matriculated six students into a three- year Accelerated Competency-Based Education in Primary Care (ACE-PC) program in 2014.
• The Louisiana State University School of Medicine is planning a three-year program in partnership with the University of Louisiana–Lafayette.58
• Our institution, the Medical College of Wisconsin, matriculated 26 students in 2015 to a three-year program at our new Green Bay regional campus, and plans for 20 to 25 more per class to a three-year program at our Central Wisconsin campus in 2016.

많은 사람들이 3년제 프로그램이 성공적으로 도입될 만큼 미국 내 환경이 충분히 바뀌었는지 물어본다. 이에 대해 우리는 위에서 언급한 프로그램들이 그 규모(정원)가 작고, 특정 그룹의 학생을 대상으로 하고 있다는 것을 말하고 싶다. 향후 면밀한 검토가 필요하다.

Some may ask whether circumstances have changed sufficiently to enable successful implementation of three- year medical education programs in the United States. We note that the programs described above are small in scale and involve a limited number or niche group of students rather than the entire student body. Thus, these new programs should be studied carefully.

3년제 교육과정의 장점

Potential Advantages of Three- Year Medical School Curricula

유사하게, 3년제 교육과정은 의사과학자로서의 진로를 고려하는 학생들에게도 적용할 수 있다. 예컨대 Columbia의 Fast-Track MD 프로그램은 학생들이 자연과학의 PhD를 할 수 있도록 의과대학 과정을 3년에 마무리짓게 해준다.

Similarly, three-year programs could provide pathways into medicine for scientists whose training and experiences overlap with the basic science component of the medical school curriculum. For example, as described above, Columbia’s Fast-Track MD program allows individuals with PhDs in life science disciplines to complete medical school in three years.51

학생들의 빚 축소와 빠른 임상경험

Reduced education debt burden and more rapid entry into clinical practice

3년제 프로그램은 학생들의 빚을 줄여주고 임상경험을 더 쌓을 수 있는 추가적인 시간을 제공한다. 2012-2013학년도에 의과대학 졸업생들의 평균 빚은 17만 달러였다.

It has been discussed widely that three- year programs could reduce lifetime student debt burden and provide an opportunity for an additional year of productive clinical practice. For the 2012–2013 academic year, the mean education debt for graduating medical students in the United States was over $170,000.59

의과대학 교육에 새로운 기회 창출

Creation of opportunities to enrich medical school education

3년제 프로그램은 단순히 교육과정을 빠르게 만드는 것이 아니다. 이는 4학년 시기를 자신의 진로 (석사 학위와 같은)에 맞게 사용할 수 있게 해준다. 예컨대 MPH 학위와 같은 것이 일차의료나 공공의료를 원하는 학생들에게 제공될 수 있다. MBA나 역학, 보건행정, 공공정책 등도 가능하다.

Three-year medical school curricula are not simply accelerated pathways to primary care residency and practice. They also could provide opportunities for students to use the fourth year to obtain training relevant to their chosen careers, perhaps through master’s degree programs. For example, a master of public health degree would provide opportunities for students who want to work at the interface of primary care and public health. Other relevant master’s degree programs include business administration, epidemiology, health care administration, and public policy.

어떤 사람들은 의과대학 4년의 구조가 거의 대부분에 존재하고, 연구 일렉티브, 서브인턴십, 연구참여, 구직 면접, 회복기간 등으로 활용되는 것에 의문을 표한다. 많은 학생들이 일렉티브를 전공의에 선발되기 위한 오디션의 개념으로 참여한다. 분명 이러한 로테이션의 가치가 있긴 하나, 모든 학생들이 해야 할까?

Some have questioned the value of the fourth year of medical school,60 the structure of which has remained fairly similar across time and institutions and typically offers clinical and research electives, subinternships, research experiences, job interviews, and “recuperation” time. Many students forgo electives to “audition” for residencies during their fourth year. Certainly, these rotations have value, but do all students need the fourth year of medical school? It

의사가 아닌 보건의료인과 과학자의 진로 변환

Transitional pathways for nonphysician health care providers and scientists

3년제 프로그램이 성공하려면 고려되어야 할 점들이 있다.

There are several key considerations that should be addressed to ensure success. 

• Institutions with three-year curricula should choose their matriculants wisely and seek student input to optimize these programs. 
• They should provide robust support systems for students and deal constructively with burnout. 
• They should develop strong faculty support and faculty development programs to address faculty fatigue and to aid new community-based educators. 
• They should create transition or deceleration pathways for students who are not able to complete the accelerated curriculum within three years. 
• Finally, they should cultivate relationships with residency programs or create their own destination residency programs for students in their three-year curricula.

33 Dienstag JL. Evolution of the New Pathway curriculum at Harvard Medical School: The new integrated curriculum. Perspect Biol Med. 2011;54:36–54.

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Acad Med. 2015 Aug 11. [Epub ahead of print]

The Merits and Challenges of Three-Year Medical School Curricula: Time for an Evidence-Based Discussion.

Raymond JR Sr1, Kerschner JE, Hueston WJ, Maurana CA.

Author information

• 1J.R. Raymond Sr is professor of medicine, president, and chief executive officer, Medical College of Wisconsin, Milwaukee, Wisconsin. J.E. Kerschner is professor of otolaryngology and communication sciences, dean of the medical school, and executive vice president, Medical College of Wisconsin, Milwaukee, Wisconsin. W.J. Hueston is professor of family and community medicine and senior associate dean for academic affairs,Medical College of Wisconsin, Milwaukee, Wisconsin. C.A. Maurana is professor of population health, vice president for academic outreach, and director, Advancing a Healthier Wisconsin Endowment, Medical College of Wisconsin, Milwaukee, Wisconsin.

Abstract

The debate about three-year medical school curricula has resurfaced recently, driven by rising education debt burden and a predicted physician shortage. In this Perspective, the authors call for an evidence-based discussion of the merits and challenges of three-year curricula. They examine published evidence that suggests that three-year curricula are viable, including studies on three-year curricula in (1) U.S. medical schools in the 1970s and 1980s, (2) two Canadian medical schools with more than four decades of experience with such curricula, and (3) accelerated family medicine and internal medicine programs. They also briefly describe the new three-year programs that are being implemented at eight U.S. medicalschools, including their own. Finally, they offer suggestions regarding how to enhance the discussion between the proponents of and those with concerns about three-year curricula.This is an open-access article distributed under the terms of the Creative Commons Attribution-Non Commercial-No Derivatives License 4.0 (CCBY-NC-ND), where it is permissible to download and share the work provided it is properly cited. The work cannot be changed in any way or used commercially.

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