도심의료와 공공의료 교육: TRUIMPH (Acad Med, 2013) [출력완료]

도심의료와 공공의료 교육: TRUIMPH (Acad Med, 2013)

Training in Urban Medicine and Public Health: TRIUMPH

Cynthia Haq, MD, Marjorie Stearns, MPH, John Brill, MD, MPH, Byron Crouse, MD,

Julie Foertsch, PhD, Kjersti Knox, MD, Jeffrey Stearns, MD, Susan Skochelak, MD, MPH,

and Robert N. Golden, MD

미국이 보건의료에 비용을 많이 쏟지만, 그 성과는 별로임.

Although the United States spends more money on health care than any other country—$8,362 per person in 20101—the population does not experience the best health outcomes and currently ranks 51st in life expectancy.2

인구집단의 건강에 영향을 미치는 요소로 '일차의료 접근성'은 핵심 요인이다. 일차의료에 초점을 맞춘 보건시스템은 more effective, equitable, and efficient health services 과 관련있으며, 더 나은 인구집단의 건강을 더 적은 비용으로 달성하게 해준다. 보건의료개혁이 수백만의 미국인들에게 financial access를 높여주었을 수는 있으나, 충분한 수의 보건의료전문직이 없다면 의료서비스는 제공될 수 없다.

Access to primary health care is a key factor influencing the health of populations. Research has shown that health systems focused on primary care are associated with more effective, equitable, and efficient health services and that they achieve better population health outcomes at lower costs.4 Although health care reform may increase financial access to health care for millions of Americans, health services cannot be delivered without sufficient numbers of appropriately skilled health professionals distributed according to the needs of the population.5

6천만명 이상, 혹은 20%의 미국인이 일차의료 Health Professional Shortage Areas (HPSAs)에 거주하고 있다.

More than 60 million, or nearly 20%, of Americans are living in primary care Health Professional Shortage Areas (HPSAs).6

일차의료의사의 부족과 더불어, 국가적으로 대부분의 전공과에 있어서 의사의 부족을 겪고 있다. AAMC는 2015년까지 3만명의 일차의료 인력과 3만3천명의 비-일차의료 의사가 부족할 것이라고 예상하였으며 2025년까지 이는 더 심해질 것으로 예상했다 그러나 의사들이 전공을 정하고 어느 지역에서 진료할지를 정하는데 더 높은 경제적 보상이 있는 쪽이 어딘가를 우선적으로 고려하는 한 단순히 의사를 더 양성하는 것 만으로는 이러한 전공과 지역적 불균등분포 문제를 해결하지 못할 것이다.

In addition to the increasing shortage of primary care physicians, the nation is experiencing a shortage of physicians across most specialties. The Association of American Medical Colleges projects a shortage of more than 30,000 primary care and 33,000 non-primary-care physicians by 2015—and worsening shortages projected through 2025.5 Increasing the production of physicians will not resolve these specialty and geographic maldistributions as long as physicians perceive financial incentives in choosing select specialties and/or in practicing in communities that generate higher levels of reimbursement.

 

미국 의과대학에서 의료취약인구를 위한 교육과정을 살펴보면 다양한 형식을 보여주며, 학생의 농촌/도시 환경에 engagement도 다양하게 나타난다.

A review of U.S. medical school programs designed to prepare students to care for medically underserved populations reveals a variety of formats and types of student engagement in rural and urban environments.

 

포멧은 이러한 것들

Formats range from

• short electives or required courses10,11 to
• extended, multiyear commitments combining formal didactics,
• immersion in clinically underserved populations, and
• community health projects.12–25

 

다음의 측면에서 다양하다.

These programs vary in their

• 목적 focus areas,
• 내용 curricular content,
• 학생 참여 정도 levels of student involvement,
• 지원/선발 과정 application/ selection processes, and
• 성과 outcomes.

 

연구에서 학생의 공감과 지식의 향상을 보고하였으며, 일차의료 진로 선택이 많아졌고, HPSA에서 진료할 것으로 결정하는 것이 많아졌다.

Several have demonstrated increases in participating students’ empathy and knowledge,19,24 selection of primary care careers,15,17,19,23 and decisions to practice in HPSAs12,13,15,17,18,23 when compared with nonparticipants.

2005년 위스콘신 지역의 심각한 건강불균형에 대한 대응으로, University of Wisconsin (UW) Medical School 는 공공의료를 의학교육의 핵심 요소 통합하고자 하는 비전을 가지고 교육과정을 개혁하며 학교의 이름도 SMPH로 바꾸었다.

In 2005, in response to substantial health disparities in Wisconsin,26 the University of Wisconsin (UW) Medical School launched a bold curricular transformation with the vision of incorporating public health as an integral component of medical education. The school changed its name to the School of Medicine and Public Health (SMPH),

위스콘신 지역 인구의 17%가 농촌 혹은 도시의 일차의료 의료인력부족지역(HPSA)에 거주하고 있다. 

More than 17% of the people of Wisconsin live in federally designated primary care rural or urban HPSAs29—a percentage similar to national shortages.6

SMPH는 이러한 요구에 대응하기 위한 새로운 프로그램을 만들었고  Wisconsin Academy for Rural Medicine 는 농촌 의사를, Training in Urban Medicine and Public Health (TRIUMPH)는 도시 의사를 양성한다.

The SMPH has created new programs to respond to these needs. The Wisconsin Academy for Rural Medicine prepares rural physicians,30 and its sister program, Training in Urban Medicine and Public Health (TRIUMPH), prepares urban physicians.31

트라이엄프

TRIUMPH

목적과 감독

Program goals and oversight

목적 

TRIUMPH is designed to prepare medical students to become community- responsive physician leaders32 who are able to promote health equity for urban populations in Wisconsin and beyond.

프로그램의 주요 목표

The program

• 지역사회에 완전한 몰두 immerses students in clinical work within urban communities,
• 롤모델 노출 exposes them to positive physician role models and community leaders,
• 지역사회 문제에 참여(관여) engages them in addressing complex community and public health problems, and
• 일차의료 진로 선택 권장 encourages them to consider primary care or subspecialty medical careers serving urban underserved populations.

 

밀워키 캠퍼스

Milwaukee Academic Campus

TRIUMPH 학생들은 대부분의 임상실습을 밀워키에서 보냄. Aurora Health Care가 중요한 기능을 하는 지역

The SMPH has an established statewide network of urban and rural clinical training sites at which most students rotate during their third (M3) and fourth (M4) years of medical school. TRIUMPH students, however, complete the majority of their clerkships in Milwaukee, 90 miles from the main campus in Madison. Milwaukee is home to Aurora Health Care, a not-for-profit hospital and clinical network with a strong commitment to medical education,33 where up to 30% of UW medical students have participated in required clerkships for decades.

밀워키 특징 

The City of Milwaukee

• contains the greatest concentration of Wisconsin residents living in a metropolitan HPSA (n = 317,721) and
• requires an estimated 22 additional primary care physicians to end its significant physician shortage.29

 

Of the city of Milwaukee’s nearly 600,000 inhabitants,

• 34 41% have public health insurance and
• 16% have no health insurance.35 In Milwaukee,
• 38% of all families with children under 18, and
• 46% of all children, live in poverty.

 

The infant mortality rate for African Americans born in Milwaukee in 2009 was 14.7/1,000 live births—the seventh worst among large cities in the nation, and more than twice as high as the rate for white infants.36

 

학생 모집과 선발

Student recruitment and selection

SMPH웹사이트를 보고 TRIUMPH에 대해서 학습함 

Students learn about TRIUMPH from the SMPH’s Web site, through classmates, and during brown bag information sessions held monthly during the fall semester.

• 2학년때 지원
  They apply and are selected during their second year of medical school. Students interested in any specialty may apply as long as they also have an interest in practicing in urban underserved areas.
• 에세이 제출, 추천서 제출
  Applicants submit essays describing their background and their experience working with underserved populations or with people of lower economic status; they also submit letters of recommendation.
• The dean of students 가 지원서 검토
  The dean of students reviews applicants to confirm positive academic standing and professional conduct.
• 위원회(교수, 지역사회 리더, 4학년 학생)에서 선발
  A committee of faculty, community leaders, and two M4 TRIUMPH students selects applicants.
• 대부분 지역사회 봉사 경험이 있음
  Most applicants have participated in community service prior to and/or during the first two years of medical school.
• 선발 기준은 'strong service ethic and motivation to work in low-resource settings'인데, 그 이유는 이전 연구에서 이 요인이 미래에 취약인구집단을 위해 봉사할 것인가를 예측해주었기 때문에.
  Selection criteria include demonstration of a strong service ethic and motivation to work in low-resource settings, because prior studies have confirmed that these factors predict a greater likelihood of future service to underserved populations.37

3학년때 밀워키지역으로 이동. Aurora Health Care 가 집 제공, 추가 인센티브는 없음. 6명(2009년)으로 시작해서, 지금은 학년당 16명 (총 학생의 10%)

Students relocate from Madison to Milwaukee to begin TRIUMPH during their M3 year. Aurora Health Care provides housing; there are no additional financial incentives. Program capacity was initially 6 students per year (in the 2009 pilot) and has recently expanded to 16 per year—approximately 10% of the total class.

대부분의 TRIUMPH학생은 10~15개월을 밀워키에서 보냄

most TRIUMPH students spend 10 to 15 months in Milwaukee over the course of their last two years of medical school,

 

교육과정 설계와 조직

Curriculum design and organization

Fishbein and Ajzen의 theory of reasoned action 을 따라서 설계함. 여기서는 attitudes 와 subjective norms 가 미래의 행동과 진로 선택에 영향을 준다고 함.

The curriculum design reflects Fishbein and Ajzen’s38 theory of reasoned action, which proposes that attitudes and subjective norms are likely to shape future behavior and career decisions.39

Montefiore Social Medicine residency program의 프레임워크를 적용하여 설계함. 여기에 다른 원칙들도 가미됨.

TRIUMPH’s curriculum designers adapted the framework from the Montefiore Social Medicine residency program,40 revising the goals and activities to be appropriate for medical students and enhancing personal and peer support. Whereas TRIUMPH builds on the foundational work of Montefiore and others, it provides a unique blend of principles from

• asset-based community development,41
• community-oriented primary care,42,43
• servant leadership,44
• evidence-based public health,45
• culturally responsive health care,46 and
• mindful practice47 to cultivate compassionate care for self, for others, and for communities.48

지역사회와 공공보건 프로젝트

Community and public health projects.

1주에 한나절.

Students are excused from clinical duties to engage in service–learning projects one half-day per week throughout the duration of the program.

세미나와 휴머니즘 라운드

Seminars and humanism rounds.

프로젝트 세미나와 휴머니즘 라운드가 번갈아가면서 진행.

Project seminars alternate with humanism rounds during which students share clinical and community narratives with personal reflections.

 

휴머니즘 라운드에서는 다음을 논의함

Humanism rounds provide a supportive environment for students to discuss

• patient and community dilemmas or conflicts;
• progress and challenges; and
• reflections, responses, and feelings.

서로 경청하고, 공감하고, 비판단적 자세로.

Peers are instructed to listen carefully and to respond with compassion and in a nonjudgmental fashion rather than to focus on clinical issues.

임상 실습

Clinical rotations.

대부분의 4학년 실습을 밀워키에서 보냄
TRIUMPH students complete the majority of their M4 rotations in Milwaukee while they continue the core curriculum seminars and projects.

4개월까지 밀워키 외 지역에서 다음의 것을 할 수 있음.

Students are allowed to spend up to four months of their senior year away from Milwaukee

• to complete rotations that are not offered in the city,
• to engage in rotations in residency training sites, or
• to pursue global health electives.

6주짜리 M4 preceptorship을 이수해야 함

All SMPH students are required to complete an M4 preceptorship, a six-week full-time rotation to enhance their clinical skills.

TRIUMPH 학생들은 도시의사의 inspiring 롤모델과 함께 전 학년기간동안 지속적으로 함께 일함

TRIUMPH students, however, work specifically with inspiring urban physician role models in a longitudinal fashion over the entire year.

대부분의 4학년 TRIUMPH 학생들은 연방에서 인정받은 커뮤니티 헬스센터의 preceptor와 매칭됨

Thus far, most M4 TRIUMPH students (24 out of 31) have been matched with preceptors in federally qualified community health centers.

비용

Institutional costs.

상당한 비용이 들어감(학생, 지역사회, 파트너 기관)

The SMPH has invested significant institutional resources to ensure that the program provides benefits for students, communities, and institutional partners.

Community organizations receive financial support for project mentors ($1,500 per student), and

community members receive honoraria for organizing community events and presentations (a total of $4,000 per year).

 

학생당 8300달러

All of these expenses result in a total of net new costs of about $200,000 per year for 24 students (16 M3 + 8 M4 students), or about $8,300 per student.

 

프로그램 평가

Program evaluation

몇 가지 어려움

• 이미 의료취약지역에 강력한 흥미를 가진 학생이 지원한다는 것. Confound 가능성.
  One challenge in evaluating programs like TRIUMPH is that they purposely admit students who already have a strong interest in practicing in medically underserved areas, and this selection effect results in preexisting differences between program students and their peers that confound key outcomes.
• 핵심 결과라 할 수 있는 '취약지에서의 진료를 선택하는 TRIUMPH 졸업생' 결과는 수 년 뒤에나 나온다
  A second challenge is that the key outcome—in this case, the number of TRIUMPH graduates practicing in urban underserved areas, especially in Wisconsin—takes many years to emerge.
• 어떤 이유로든 TRIUMPH과정 이수가 딜레이된 학생을 어떻게 포함시킬 것인가.
  A further complication is determining in which “cohort” to include the data (for analysis) of TRIUMPH students who delay completing medical school for some reason.
• 프로그램 자체가, 그리고 프로그램 평가가 시간에 따라/매년 달라진다는 것.
  A final challenge, especially in doing statistical analyses and making inferences regarding program effects, is that the program and its evaluation have changed over time (as should be the case for programs that use data to make improvements), so that what students experience in different years/versions of TRIUMPH gradually changes.

어떤 학생은 3학년, 4학년의 전체(15개월)을 다 경험한 반면, 어떤 학생은 일부 (3학년 6개월)만 경험함.
One key change—and a key distinction among TRIUMPH students of various cohorts—is that some have experienced a “full dose” of the program (six months of their M3 year and all nine months of their M4 year), whereas others have experienced only a partial dose (six months of their M3 year).

Method

 

1. 3학년과 4학년 매2주마다 집중 과정 이수 후 설문

1. Surveys of M3 and M4 students after each of their two-week intensive courses. Each survey, comprising 40 to 45 items, asks students to rate and comment on each session or activity, rate how well the course met each of its goals, and offer suggestions for improvement.

 

2. TRIUMPH학생 대상 설문 (학생의 태도 변화를 매년 측정)

2. Year-end surveys of all TRIUMPH students that allow the program both

• to measure annual changes in students’ attitudes toward practicing in underserved areas and
• to determine the impact and effectiveness of all aspects of the TRIUMPH curriculum.

Each survey, comprising 36 to 40 items, asks students to

• rate the effectiveness of and
• comment on all aspects of that year’s program.

 

It also asks students to rate the program’s overall impact

• on their interest and confidence in working with underserved urban populations and
• on their knowledge, skills, and attitudes related to such work.

 

3. 멘토의 학생에 대한 평가(학년 말), 멘토 자신에 대한 응답

3. Year-end surveys of the community mentors that gather mentors’ ratings (on a five-point scale where 1 = Low and 5 = High) of students’

• dedication to the project,
• curiosity/drive to learn,
• professionalism, and
• flexibility/ability to adapt to circumstances.

Mentors also

• rate five aspects of the mentoring experience,
• provide information about their willingness to continue serving as mentors, and
• make suggestions on how to improve the program experience for mentors.

4. 모든 TRIUMPH 학생의 포커스그룹

4. One-hour, tape-recorded, year-end, in-person focus groups with all the students in a cohort, facilitated by the TRIUMPH evaluator (J.F.), during which students discuss in- depth the effects of, the challenges they experienced during, and any suggestions they have for improving TRIUMPH.

5. 성적
5. Participating students’ course grades for all four years of medical school, Step 1 and 2 board exam scores, clerkship SHELF scores, and year-end professional skills assessment scores.

 

6. TRIUMPH학생과 다른 UW 의과대학생의 졸업후설문(졸업 후 1년, 3년, 6년)

6. Postgraduation surveys of TRIUMPH and other UW medical students at one year (23 items), three years (27 items), and six years (27 items) post graduation that ask, among other things,

• the graduate’s specialty,
• whether he or she is currently and/ or is ultimately planning to practice in Wisconsin and/or in medically underserved areas, and
• the degree to which she or he is engaged in various public health activities.

Results

Outcomes for the students who enrolled in TRIUMPH in 2010

Outcomes for the students who enrolled in TRIUMPH in 2011

 

 

고찰

Discussion

포커스그룹 결과를 보면 프로그램이 낮은 SES의 의료취약인구에 대한 헌신과 자신감을 심어주었다. 무기력helpless에서 희망hopeful로 태도가 바뀌었으며, 레지던트 전공 선택에 있어 중요한 시기에 취약인구와 함께하려는 정신spirit을 심어주었다.

Comments from focus groups of students reflect that the program has reinforced their commitment to and increased their confidence in working with underserved populations and people of lower socioeconomic status. Students have shared that their attitudes shifted from helpless to hopeful, and that the program has preserved their spirit to work with underserved populations during the critical period of residency specialty selection.

원래 흥미는 있었지만 TRIUMPH가 나의 진로 목표를 더 굳건히 해주었고, 효과적인 지역사회 의사와 대변인이 되기 이한 자신감과 실용적 도구practical tool을 주었다.

I was interested in working with underserved populations, but TRIUMPH solidified this as my career goal and gave me the practical tools and confidence to be an effective community physician and advocate.

학생들의 교육경험을 향상시켜주고 취약지역에서 살아남은 긍정적인 롤모델과 함께 의료취약 현장에서의 실제 근무기회를 주었다. 의과대학생들은 사실적 지식을 암기하고, 과목 요건을 충족시키고 임상환경의 진료에 익숙하긴 하나, 대부분은 지역사회에서, 그리고 다학제간 팀에서 복잡한, 장기적 문제를 해결하기 위해 일해본 경험이 적다.

Further, TRIUMPH enhances the educational experiences of students and gives them an opportunity to work in underserved practices with positive role models who thrive in such settings. Medical students are familiar with memorizing facts, meeting precise course requirements, and practicing in clinical environments, yet most have limited experience working with communities and interdisciplinary teams to address complex, long-term problems.

대부분의 학생들은 상당한 채무educational debts를 지게 되며, 어떻게 취약인구를 위해 일하면서 개인/가정의 요구와 진로 사이의 균형을 맞출 수 있을 것인지 고민한다. 다음의 것들이 가능한 진로 옵션을 제공해준다.

• 롤모델과 커뮤니티 프로그램에 대한 노출
  Exposing students to successful, enthusiastic physician role models and vibrant community health programs,
• 대출 상환 플랜 정보 제공
  informing them about loan repayment plans, and
• 비경제적 보상을 보여줌
  demonstrating the nonfinancial rewards related to working with disadvantaged populations

Additionally, most medical students carry substantial educational debts and are concerned about how to balance their personal and family needs with careers dedicated to working with the poor and medically underserved. Exposing students to successful, enthusiastic physician role models and vibrant community health programs, informing them about loan repayment plans, and demonstrating the nonfinancial rewards related to working with disadvantaged populations provide them with viable career options.

UW SMPH 에도 영향을 미쳤다. "대학의 사회적 책무에 대한 미션을 실현할 수 있었으며, 학생들이 지역사회 보건의 대변인이 될 수 있게 하는 새로운 교육과정 도구를 제공하였고, asset-based 접근법을 적용하였고, 스스로 성찰할 수 있었다"

TRIUMPH has also influenced the host institutions, including the UW SMPH itself. One advisory committee member has noted that the program has “

• actualized the school’s mission of social responsibility,
• provided new curriculum tools to prepare students to serve as health advocates,
• applied asset-based approaches to community health, and
• promoted self-reflection.”

레지던트 프로그램에도 영향을 주기 시작하였다

TRIUMPH is beginning to influence residency programs, too. Graduates have initiated efforts to enhance community engagement at the postgraduate level.

지역사회 조직도 개선시켰다.

Finally, TRIUMPH improves community organizations as well.

아직 여러 개념적/Logistic/재정적 과제가 남아있다.

Although TRIUMPH has achieved notable short-term successes, the program has encountered significant conceptual, logistical, and financial challenges.

• 개념적 A conceptual barrier: 학생의 멘토와 롤모델 부족
   is the reality that relatively few physicians have successfully integrated clinical medicine and public health into their careers. Therefore, recruiting physicians as well as other community health leaders to serve as student mentors and role models has been essential.
• 로지스틱 Logistically: 교육과정의 과포화
  the medical school curriculum is overcrowded with content, requirements, and duty hours, so clear and regular communication with clerkship directors has been necessary
• 시간을 확보하고 to protect student time,
• 효율적으로 내용을 교육하고 to deliver content efficiently, and
• 지역사회와 공공보건이 향상됨을 보여주면서도 to demonstrate that community and public health work would enhance and
• 학생의 임상 수행능력에는 악영향을 미치지 않게 하는 것 not adversely affect students’ clinical performance.
• 재정적 Financially: 재정적 지원이 열악했던 국가 상황
  , the program was launched at about the same time as the economic recession and at a time when the school was facing serious budget shortfalls due to reductions in state funding. Nevertheless, the school and the state have sustained their financial support. In fact, because of strong student, faculty, and community interests, the program even expanded during this period of strained resources.

 

 

 

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Acad Med. 2013 Mar;88(3):352-63. doi: 10.1097/ACM.0b013e3182811a75.

Training in Urban Medicine and Public Health: TRIUMPH.

Haq C1, Stearns M, Brill J, Crouse B, Foertsch J, Knox K, Stearns J, Skochelak S, Golden RN.

Author information

• 1University of Wisconsin School of Medicine and Public Health, Madison, Wisconsin 53705, USA. clhaq@wisc.edu

Abstract

PURPOSE:

The number of U.S. medical school graduates who choose to practice in health professional shortage areas (HPSAs) has not kept pace with the needs of society. The University of Wisconsin School of Medicine and Public Health has created a new program that prepares medical students to reduce health disparities for urban medically underserved populations in Milwaukee. The authors describe the Training in Urban Medicineand Public Health (TRIUMPH) program and provide early, short-term outcomes.

METHOD:

TRIUMPH integrates urban clinical training, community and public health curricula, longitudinal community and public health projects, mentoring, and peer support for select third- and fourth-year medical students. The authors tracked and held focus groups with program participants to assess their knowledge, skills, satisfaction, confidence, and residency matches. The authors surveyed community partners to assess their satisfaction with students and the program.

RESULTS:

From 2009 to 2012, 53 students enrolled in the program, and 45 have conducted projects with community organizations. Participants increased their knowledge, skills, confidence, and commitment to work with urban medically underserved populations. Compared with local peers,TRIUMPH graduates were more likely to select primary care specialties and residency programs serving urban underserved populations. Community leaders have reported high levels of satisfaction and benefits; their interest in hosting students exceeds program capacity.

CONCLUSIONS:

Early, short-term outcomes confirm that TRIUMPH is achieving its desired goals: attracting and preparing medical students to work with urban underserved communities. The program serves as a model to prepare physicians to meet the needs of urban HPSAs.

PMID:

 

23348092

 

[PubMed - indexed for MEDLINE]