미래 의사 선발: 미래 보건의료인력의 핵심(Acad Med, 2013)

미래 의사 선발: 미래 보건의료인력의 핵심(Acad Med, 2013)

Selecting Tomorrow’s Physicians: The Key to the Future Health Care Workforce

Kelly E. Mahon, MA, Mackenzie K. Henderson, and Darrell G. Kirch, MD

최극 미국 내 의료혁신은 세 가지 목적을 가지고 있다. 하나는 개개인의 건강을 향상시키는 것, 둘째는 인구집단의 건강을 향상시키는 것, 그리고 마지막으로 비용을 낮추는 것이다. 이 목적을 달성하기 위해서 전통적으로 '자율성'을 바탕으로 진료를 해왔던 의사들은 점차 팀-기반 진료 모델의 구성원이 될 것을 요구받고 있다.

Recent health care reform efforts in the United States have focused on the “triple aim”1 of improving health care for individuals, improving population health, and lowering costs. Physicians, who traditionally have practiced with considerable autonomy, will be required to become members of the team-based patient care models that are necessary to achieve these goals

의과대학 입학: 역사적 유물

Medical School Admissions: A Historical Legacy 

플렉스너가 20세기 초반, 북미 전역에 걸쳐 의과대학을 평가했을 때, 의학전교육요건(premedical education requirements)과 의과대학 입학절차가 부실하다는 점을 지적했다. 이는 미국에 기준에 미달하는 의과대학들이 횡행하는 이유이며 "의학교육과 의료에 전례없는 해를 끼칠 수 있는 토양"이라고 묘사했다.

When Flexner traveled across North America in the early 20th century, he decried the lack of rigor in premedical education requirements and medical school admission processes, describing the proliferation of substandard medical schools in the United States as “the fertile source of unforeseen harm to medical education and to medical practice.”3 

플렉스너 보고서의 중요한 유산 중 하나는, 미래 의사가 최소한의 기초과학 지식을 갖춰야 한다는 것이다.

The key enduring legacy of the Flexner Report is its argument that future physicians should possess a minimum threshold of knowledge in the basic and natural sciences.4 

MCAT시험은 의과대학지원자의 과학지식에 대한 성취 정도를 평가할 뿐 아니라, GPA와 더불어 의과대학에서의 성적, 의사면허시험에서의 성적을 예측하는 도구로 활용되어 왔다.

The MCAT exam has become the tool of choice not only to measure medical school applicants’ mastery of scientific content, in conjunction with their grade point averages, but also to act as a reliable predictor of success in medical school and initial licensure examinations.5 

오랫동안 의과대학 지원자를 GPA나 MCAT 점수를 넘어선 어떤 기준에 의해서 평가해야 한다는 열망이 있었으며, 1980년대 초반에는 의과대학 지원자를 단순한 예비 학자가 아니라 하나의 인간으로서 평가하는 live interview가 등장하였다. 최근 면접이 개선됨에 따라 면접이 스크리닝 도구로서 강점을 가지게 되었음에도 불구하고, 면접은 전통적으로 약하고, 주관적이고, 비일관된 도구라고 인식되어 왔다.

There long has existed a clear need to assess applicants beyond their grades and MCAT scores. By the early 1980s, live interviews emerged as a tool to help admissions officers get to know an applicant as a person and not merely as a scholar.6 Although recent innovations, as we will discuss below, are showing great promise to strengthen the interview as a screening tool,7 interviews traditionally have been a relatively weak, subjective, and inconsistent means by which to assess medical school applicants.8

미래 의료인력 선발: 의료 혁신의 핵심

Selecting the Future Physician Workforce: A Key to Health Care Reform

플렉스너의 연구 결과에 따라서 만들어진 입학 시스템이 20세기와 21세기 의사들이 전통적인 자연과학 분야의 튼튼한 토대를 갖출 수 있도록 성공을 거둬온 것은 사실이다. 그러나 이는 역설적으로 보건의료 시스템을 변혁할 수 있는 혁신적 의사를 찾아내는데는 약점을 보여왔다.

Although the admission system created in response to Flexner’s findings has been successful in ensuring that 20th- and 21st-century physicians are grounded in the natural and traditional life sciences, it has fallen short in identifying the innovative physicians who can transform the health care system.

미국의 의료는 비용은 많이 들고 그 성과는 나쁘다.

The United States has the highest health care spending when compared with similar developed nations, yet it has poor outcomes on numerous measures, including life expectancy, infant mortality, and obesity.9

게다가 미국의 건강 격차는 심하기로 악명높다.

In addition to high costs and poor outcomes, the United States suffers from pernicious health disparities along the lines of race, ethnicity, and geographic location.12 

2013년 2월, 100명 이상의 의과대학 리더가 회담을 가지고 현재의 의료비용의 지속불가능성에 대해 논의했다. 여기서 나타난 합의는 진정으로 높은 가치를 가지는 의료시스템만이 비용을 줄일 수 있으며, 이를 위해서는 진정한 재설계가 필요하다는 것이다.

In February 2013, more than 100 leaders of medical schools and teaching hospitals convened at a summit hosted by the Association of American Medical Colleges (AAMC) to address the unsustainability of current health care costs. A consensus emerged that creating a truly high-value health system will require more than revenue expansion and expense reduction; it will entail a true redesign.15

의사들은 시스템 기반 사고를 할 수 있어야 하며, 국가의 보건의료시스템에 긍정적 변화를 이끌어나갈 수 있어야 한다.

Physicians must have the capacity to engage in systems-based thinking and work in teams to lead positive change in the nation’s health care system.

의과대학 입학을 다시 생각하기: 여러 요인의 합류

Rethinking Medical School Admissions: A Confluence of Factors

의과대학 입학에 대해 생각할 때 몇 가지 함께 고려할 요인이 있다.

Several major factors have converged to influence thinking about medical school admissions. 

• national debate surrounding health care reform 
• passage of the Patient Protection Affordable Care Act— 
• issues regarding professionalism 

이렇게 여러 요인들이 합해짐에 따라서, AAMC는 이를 지금까지 이뤄진 정기적인 MCAT시험에 대한 검사에 대한 것을 넘어서 더 넓은 차원에서의 입학절차 개혁을 이룰 기회로 보았다. AI를 창단하였으며 그 목적은 다음과 같다.

In this confluence of factors, the AAMC recognized an opportunity to consider a broader transformation of the medical school admissions process beyond its regularly scheduled review of the MCAT exam.19 The association launched its Admissions Initiative (AI), aimed at transforming the way in which medical school applicants are assessed and selected in order to identify those who will become the kinds of physicians best suited to practice in a dynamic health care environment. Specifically, the AI is designed to 

• support the implementation of holistic admissions, 
• explore ways to ease the transition to competency- based learning and assessment in undergraduate medical education, and 
• examine new and better ways to measure core, entry-level competencies for medical students.20 

AAMC와 전 국가적으로 지난 100년간 의과대학을 지지해온 입학 시스템이 자연과학 뿐 아니라 '좋은 임상 매너'를 갖춘 의사가 되기 위한 대한 탄탄한 기초를 갖춘 의사 양성을 위해서 개선되어야 한다는 인식이 있었다. 이는 더 높은 수준의 프로페셔널리즘, 잘 다듬어진 의사소통기술, 미래의 환자들을 이해하고 상호작용할 수 있는 능력 등을 포함한다.

There was increased recognition at the AAMC and nationally that the admission system that had served medical schools well for the past century could be improved to identify those future physicians with both a strong foundation in the natural sciences and a “good bedside manner,” that is, a high degree of professionalism, well-honed communication skills, and an ability to interact with and understand their future patients.21–23

전인적 학생선발

Supporting Holistic Admissions

전인적 학생선발(Holistic admissions)은 AI의 핵심적 요소이며, 다음의 것을 의미한다.

Holistic admissions, an integral component of the AI, refers to a “flexible, highly individualized process by which balanced consideration is given to the multiple ways in which applicants may prepare for and succeed as medical students and doctors.”24

이러한 절차는 미국 대법원의 'holistic review'를 따른 것으로, 2003년 만들어졌으며, 개개인에 대해서 평가를 할 때 그 지원자가 교육환경의 다양성에 어떻게 기여할 수 있는가를 고려해야 한다는 것이다. 전인적 학생선발은 미션에 기반하여, 광범위하게, 각 기관별로, 지원자 전체에 걸쳐 일관되게 적용되어야 한다. 세 가지 목표가 있다.

This process complies with the U.S. Supreme Court’s “holistic review” rubric, which was established in 2003 by Grutter v. Bollinger, and calls for an individualized review of each applicant that considers how that applicant might contribute to a diverse educational environment. Evaluation criteria for a holistic review process must be mission driven, broad based, institution-specific, and applied across the applicant pool consistently.25 Holistic review has three goals: 

• to assess applicants’ academic readiness for medical school, 
• to identify and assess applicants’ interpersonal and intrapersonal competencies, and 
• to encourage diversity in medical education.

학업 준비도 재정의

Redefining academic readiness

의학교육에서의 역량 정의

To define medical education competencies, two working groups identified the skills and knowledge that future physicians should possess on entry to or completion of medical school. 

• Issued in 2009, “Scientific Foundations for Future Physicians” 
• The companion report, “Behavioral and Social Science Foundations for Future Physicians,”

최근 AAMC와 다른 다섯개의 협회가 IPEC를 구성

More recently, the AAMC and five other health associations representing schools of osteopathic medicine, dentistry, nursing, pharmacy, and public health jointly created the Interprofessional Education Collaborative (IPEC).

여기서는 전문가-간-역량을 정의하고 보고서 발간

This group initially defined four interprofessional competencies that health professions students should acquire over the course of their training: 

• values and ethics, 
• understanding roles and responsibilities, 
• interprofessional communication, and 
• teamwork. 

The result of IPEC’s efforts, “Core Competencies for Interprofessional Collaborative Practice,” represents the first time consensus has been reached about competencies required for team- based practice in a variety of settings, including in the clinic and at the bedside.27

MCAT이 현재 의과대학생 선발에서 중요한 도구로 사용되고 있기에 MR5는 2015년부터 MCAT의 개선된 버전을 사용할 것을 권고하였다. 가장 큰 변화는 행동과학, 사회과학 개념이 포함된다는 것이다.

In recognition of the MCAT exam’s status as an important tool for medical student selection,2 the fifth MCAT review (MR5) committee recommended, and the AAMC Board of Directors approved in February 2012, revisions to the MCAT exam beginning in 2015.19,28–30 One of the most prominent changes is that the 2015 exam will add a section that tests knowledge of concepts from the behavioral and social sciences to complement testing in the basic and natural sciences.31

행동, 인식, 문화, 빈곤, 심리학과 사회학의 여러 개념 등을 이해하는 것이 '좋은 의사'양성에 도움이 될 것이다.

An understanding of behavior, perception, culture, poverty, and other concepts from psychology and sociology included on the new MCAT exam contributes to the creation of the “good doctor.”32

2015 MCAT에는 비판적 분석과 추론 기술 영역이 신설된다.

The 2015 MCAT exam also adds a “Critical Analysis and Reasoning Skills” section, which is designed to help medical schools assess how applicants reason.29

새로운 MCAT은 현재의 빅데이터 환경에서 학생들은 단순 암기능력보다 자료를 찾고 추론하는 능력이 더 중요하기 때문이다.

The new MCAT section reflects the understanding that, in today’s environment of big data, students’ ability to seek and reason through information is more important than their capacity for rote memorization.

내적 역량과 대인관계 역량 도출 및 평가

Identifying and assessing interpersonal and intrapersonal competencie

전인적 평가의 두 번째 목표는 전인격을 갖춘 의사가 될 학생을 찾아내는 것이다. AAMC는 바람직한 역량을 아래와 같이 도출했다.

Holistic review’s second goal is to identify applicants who possess the traits, experiences, and attributes that will lead them to become well-rounded physicians. In 2013, the AAMC identified the most desirable interpersonal and intrapersonal competencies for entering medical students34,35 (see Table 1).

2013년 4월, 표준화 추천서 가이드라인을 배포하였고, 여기서는 지원자의 의과대학 적합성을 '지지'하기보다는 '평가'하라고 권고하고 있다. 또한 구체적인 행동과 그 결과에 초점을 맞춰 쓸 것을 권고한다.

In April 2013, the association issued standardized guidelines to aid writers of letters of recommendation. These new guidelines recommend that evaluators assess rather than advocate for the applicant’s suitability for medical school, and focus on specific observed behaviors and their consequences when writing letters of recommendations.38

또한 AAMC는 학생들의 내적, 대인관계적 역량을 평가하는데 도움이 될 두 가지 다른 방법을 고려하고 있는데, 첫 번째는 AMCAS에서 스스로의 내적, 대인관계적 역량에 대해 성찰한 내용을 기술하게 하는 것이다.

Additionally, the AAMC is considering two other methods to help medical school admission committees assess students’ interpersonal and intrapersonal competencies. The first is a potential revision to the American Medical College Application Service (AMCAS) to include a “Reflections on Interpersonal and Intrapersonal Competencies” section, where applicants would be prompted to reflect on experiences in which they have demonstrated some or all of these competencies.

두 번째는 SJT를 활용하여 평가하는 것이다. SJT는 다음과 같은 것이다.

Secondly, the AAMC is exploring the development of a situational judgment test (SJT) as another tool to probe applicants’ interpersonal and intrapersonal competencies.39 SJTs, which “confront applicants with written or video-based scenarios and ask them to indicate how they would react by choosing an alternative from a list of responses,” have shown great promise in identifying interpersonal skills.40

앞에서 말한 바와 같이 새로운 면접 기술이 등장하고 있으며 MMI는 멕마스터 의과대학에서 처음 도입되어 대부분의 캐나다 의과대학과 미국 의과대학 중 22개 이상의 의과대학에서 활용중이다.

As mentioned earlier, new interview techniques are emerging to allow medical schools to probe better dimensions of applicants’ competencies, ranging from how applicants respond to novel situations to their reactions to an ethical conflict. The multiple mini-interview (MMI) was pioneered by the Michael DeGroote School of Medicine at McMaster University and is now employed by the majority of Canadian medical schools and more than 22 U.S. medical schools.7,39

의학교육의 다양성 지탱하기

Supporting diversity in medical education

이러한 변화는 미래의 의사들이 높은 수준의 문화적 역량을 갖출 것을 요구할 것이며 이는 다음과 같이 정의된다.

This change will require that tomorrow’s physicians possess a high degree of cultural competence, which has been defined as “a set of congruent behaviors, knowledge, attitudes, and policies that come together in a system, organization, or among professionals that enables effective work in cross-cultural situations.”43

Page는 다양한 배경에서 온 다양한 사람으로 이뤄진 그룹이 문제해결을 더 잘 잘하며, 어떤 개개인보다도 뛰어나다는 것을 보여주었다. 또한 추가적으로 의과대학생들은 같은 의대생들의 다양성을 가치롭게 생각하며, 학업경험은 물론 환자를 보는 경험 역시 이 다양성에 의해서 향상된다고 평가했다.

Page44 has shown that diverse groups of people from varied backgrounds do better at problem solving and, in many ways, are smarter than any individual. Further evidence shows that “students in medical schools value diversity in their classmates and find both the academic experiences and their abilities to work with patients from differing backgrounds enhanced by this diversity.”45

100년 전, 의과대학은 표준화된 시험을 통해서 과학적 배경이 잘 갖춰진 학생을 선발하였으며, 이것이 플렉스너 보고서에서 드러난 문제를 해결하는 확실한 방법이었다. 그러나 100년이 지난 지금, 환경은 변하고 있다.

A century ago, the academic medicine community concluded that providing physicians with a rich scientific background, verified through the use of standardized tests, was the definitive answer to addressing the problems revealed by the Flexner Report. As the last 100 years have demonstrated, however, changing circumstances in the health care landscape necessitate constant transformation.

23 Swick HM. Toward a normative definition of medical professionalism. Acad Med. 2000;75:612–616. 

24 Addams AN, Bletzinger RB, Sondheimer HM, White SE, Johnson LM. Roadmap to Diversity: Integrating Holistic Review Practices Into Medical School Admission Processes. Washington, DC: Association of American Medical Colleges; 2010. https://members.aamc.org/eweb/upload/ Roadmap%20to%20Diversity%20 Integrating%20Holistic%20Review.pdf. Accessed August 21, 2013.

25 Witzburg R, Sondheimer H. Holistic review: Shaping the profession of medicine one applicant at a time. N Engl J Med. 2013;368:1565–1567. http://www.nejm.org/ doi/pdf/10.1056/NEJMp1300411. Accessed August 21, 2013.

38 Association of American Medical Colleges. Letters of evaluation guidelines. https://www.aamc.org/ initiatives/admissionsinitiative/332572/ lettersofevaluationguidelines.html. Accessed August 21, 2013.

27 Interprofessional Education Collaborative Expert Panel. Core Competencies for Interprofessional Collaborative Practice: Report of an Expert Panel. Washington, DC: Interprofessional Education Collaborative Expert Panel; 2011. http://www.aacn.nche. edu/education-resources/ipecreport.pdf. Accessed August 21, 2013.

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Acad Med. 2013 Dec;88(12):1806-11. doi: 10.1097/ACM.0000000000000023.

Selecting tomorrow's physicians: the key to the future health care workforce.

Mahon KE1, Henderson MK, Kirch DG.

Author information

• 1Ms. Mahon is a speechwriter, American Nurses Association, Silver Spring, MD. At the time of writing, she was senior executive communications specialist, Association of American Medical Colleges, Washington, DC. Ms. Henderson is senior engagement solutions specialist, Association of American Medical Colleges, Washington, DC. At the time of writing, she was research and policy analyst to the president, Association of American Medical Colleges. Dr. Kirch is president and CEO, Association of American Medical Colleges, Washington, DC.

Abstract

Recent U.S. health care reform efforts have focused on three main goals: improving health care for individuals, improving population health, and lowering costs. Physicians, who traditionally have practiced with considerable autonomy, will be required to become members of the team-based patient care models necessary to achieve these goals. In this perspective, the authors assert that medical school admissions, the selection of thefuture physician workforce, is a key component of health care reform. They review the historical context for medical school admission processes, which have placed a premium on grades and standardized test scores, and examine how admission practices are undergoing fundamental changes in order to select physicians with both the academic and interpersonal and intrapersonal competencies necessary to operate in the health caresystem of the future. The authors describe how new techniques, such as holistic review and multiple mini-interviews, are contributing to the shift toward competency-based medical education. Innovations underway at the Association of American Medical Colleges to transform medical school admissions also are explored. The authors conclude by arguing that although the admission process has great potential to transform the future healthcare workforce, major overhauls of the health care payment and delivery systems must be achieved alongside innovations in health professions education to truly transform the U.S. health care system.

PMID:

 

24128626

 

[PubMed - indexed for MEDLINE]