Faculty development through international exchange: The IMEX initiative

OLLE TEN CATE1, KAREN MANN2, PETER MCCRORIE3, SARI PONZER4, LINDA SNELL5 & YVONNE STEINERT5

1University Medical Center Utrecht, the Netherlands, 2Dalhousie University, Canada, 3University of London, UK, 4Karolinska Institutet, Sweden, and 5McGill University, Canada

배경

Introduction

교수개발이란 academic personnel에게 교육, 연구, 행정 업무에 필요한 기술을 지원하는 다양한 활동을 말한다. 대부분의 교수개발은 교수법에 집중되어 있다. 의과대학의 교수들이 다만 그 분야의 전문지식을 가지고 있고, '가르침을 받은'적이 있기 때문에 가르칠 수 있는 능력이 있을 것이라고 '추측'하는 것 뿐이지, 제대로 교수법에 대한 교육을 받은 적은 없기 때문에 이는 그다지 놀라운 일은 아니다. 지난 30년간 의학교육은 수많은 계기를 통해 진화해왔고, 그 중에는 보건의료 양상의 변화, 새로운 기술의 영향, 교육이론의 발달 등이 잇다. 그 결과, 교수들은 자신들이 배웠던 방식으로 행동하지 않게 되었다. 많은 의과대학에서는 교수법 훈련 프로그램을 제공할 뿐만 아니라 '요건화'하고 있는 경우도 있다. 지난 20년간 의학교육분야에서 최소 하나 이상의 새로운 책이 출판되고 있으며, 컨퍼런스, 논문, 학회지 등 역시 다른 여러 영역을 능가하는 속도로 빠르게 성장하고 있다.

Faculty development refers to the range of activities designed to support academic personnel in developing the skills necessary for conducting their teaching, research or administrative tasks (Steinert et al. 2006). Most initiatives focus on faculty development in teaching (Leslie et al. 2013). This is not surprising, as teachers in medical schools traditionally were not trained to teach but were assumed to have that ability because of their content knowledge and their own experience of being taught. Medical education has evolved in the past 30 years for a number of reasons, including changes in the pattern of healthcare, the impact of new technologies and advances in educational theory. As a result, teachers cannot just act like the teachers by whom they were taught. Many medical schools now offer or even require teachers to take training in teaching skills. In the past two decades, at least one new book has appeared each year on teaching in medical education, and conferences, journals and publications on medical education have shown a growth rate that exceeds many other domains (Lee et al. 2013).

교수개발 프로그램은 다양한 종류가 있을 수 있다. 또한 많은 의학교육학술지, 심포지엄, 컨퍼런스, 저널클럽 등 역시 새로운 insight와 methodology를 경험할 수 있는 기회를 제공하고 있다. 초창기에는 교수법에 대한 교수개발이 '가르치는 것'그 자체에 집중되었으나, 점차 그 목표가 넓어져서 이제는 교육과정 개발, 변화관리, 교육분야의 연구에까지 확장되었다.

The range of available faculty development initiatives includes one-on-one training consultations, local, national and international workshops and courses, certificate programs and programs leading to an academic degree (Steinert 2010; Wilkerson & Doyle 2011). In parallel, the many medical education journals, symposia, conferences and journal clubs offer a plethora of opportunities to become acquainted with new insights and methodologies in teaching and learning. While initially faculty development in teaching focused on the practice of teaching, the objectives have expanded to include wider educational functions such as curriculum development, change management and educational research (Bligh 2005; Molenaar et al. 2009; Jaarsma et al. 2013).

다양한 세팅, 문화, 대학과 접촉하면서 교수개발의 관점을 확장되었고, 한 곳에서 다른 곳으로 자리를 옮긴 교수는 스스로의 관점을 더 넓힐 수 있는 기회를 갖게 된다. 그러나 이러한 경험은 한 국가에서는 두 곳, 또는 세 곳을 넘지 않는다. 생의학 연구에 있어서 국제적 협력은 매우 권장되고 있는데, 교육 프로그램과 교수개발의 질을 높이기 위해서 국제적 협력을 못할 것도 없지 않을까? 의학교육연구의 국제적 협력은 여러 문헌에서 점차 늘어나고 있으나, 혁신과 개발에 대한 교류는 아직 그렇게 많지 않다.

The type of experiences that widen perspectives in the field should ideally involve acquaintance with different settings, cultures and schools. Faculty members who have moved from one location to a different one have the benefit of broadening their perspective, but these experiences are usually limited to two or sometimes three places within one country. International collaboration is recommended for biomedical research (Radda 2013), so why should international collaboration not similarly enhance the quality of education programs and faculty development? While international collaboration in medical education research is seen in the growing literature (Rotgans 2012), international collaboration and exchange on innovation and development is less visible.

2006년, 의학교육 연구와 개발에 적극적으로 기여하고 있는 다섯 개의 의과대학이 그들의 교수들에게 국제적 경험을 통해 더 많은 발전의 기회를 주기 위해서 공식적 협력을 시작하였다. 개개인의 교수들은 서로 다른 국가로 옮겨 다니며, 여러 국가에서 취직을 하여 international medical educator가 될 수도 있고, Harvard Macy Program이나 FAIMER program과 같이 international course들도 있지만, 우리가 아는 한 서로 다른 기관에서 교육활동이나 교수 경험 기회를 쌓으면서 international experience를 하는 프로그램은 없다. 

In 2006, five medical schools, well known for their active contributions to medical education research and development, decided to initiate a formalized collaboration to broaden the opportunities for development of their own faculty members with a significant international experience. While individual faculty members may cross borders and take up employment in a different country, thereby becoming international medical educators (McLean 2013), and international courses such as the Harvard Macy program and the FAIMER program recruit participants from across the globe (Armstrong et al. 2003; Burdick et al 2006), we know of no programs that specifically focus on the acquisition of international experiences at a variety of locations with opportunities to participate in educational activities or teach at different institutions.

방법

Method

2006년, Dalhousie University, Karolinska Institutet, McGill University, St George’s University of London and University Medical Center Utrecht는 IMEX initiative를 설립하였다.(International Medical Educators Exchange)

In 2006, Dalhousie University, Karolinska Institutet, McGill University, St George’s University of London and University Medical Center Utrecht, decided to establish the International Medical Educators Exchange (IMEX) initiative.

프로그램의 목적 : 캐나다와 유럽의 여러 의과대학에서 직접 교육에 참여함으로서 높은 수준의 교수개발을 달성하는 것.

The aim of the program is to stimulate high-level faculty development by providing an international orientation beyond the attendance at conferences and creating a network of global colleagues to broaden the understanding of medical education on a more global level. In particular, we aim to...

provide participants with a concrete experience in medical education at a number of medical schools in Canada and Europe and to 

generate exchange of ideas, discussions and 

seeds for collaboration. 

We hope the program will have an impact on personal careers and institutional development.

프로그램 규모 및 대상자

Every six months, a site visit of one week at one of the participating schools is offered to a group of six to 13 faculty, made up of one to three mostly mid-career scholars from each of the five schools, who have signed up for multiple visits over a period of two to four years. The IMEX website (www.imexchange.eu) shows a roster of site visits. We specifically target senior clinical and non-clinical teachers and curriculum developers at each of the five institutions, with an annual enrollment of one to three faculty(ies) per institution per year into the IMEX program. 

참가자 선발

All interested faculty members apply formally with a CV, a personal application letter, a letter of recommendation from their Head of the Department and a description of topics of interest they would like to explore during the week. The IMEX Board, with representatives of all five schools, approves each application. The successful applicant is then called an IMEX Scholar. Scholars must enroll for at least three site visits. 

비용

The fee for a site visit includes hotel accommodation, a social program, catering during the day, incidental expenditures and all scholarly program activities. One of the five institutions manages the central organization (financial handling, processing of applications, maintaining a website and preparing for the annual Board meetings).

프로그램 구성

A week’s IMEX program can vary somewhat, depending on the location, the special interests or activities of the institution, and the desired pursuits of the participants. However, at a minimum, it includes the following:

• an explanation of the local medical curriculum (undergraduate and/or postgraduate) and the local medical education system
• presentations on selected topics of interest by local experts
• observation of local educational activities in practice
• active observation of, or participation in, teaching
• one-on-one meetings of IMEX scholars with local colleagues who share similar disciplines or interests
• group discussions with reflections on the program of the day, exchange of experiences and presentations of personal projects to the IMEX group.
• a social event with dinner, which, among other things, serves as a team building activity

In addition, inter-scholar collaboration between IMEX site visits is encouraged but is not mandatory. In many cases IMEX scholars stay in touch and may collaborate between visits.

평가

Every site visit concludes with a short oral and written evaluation of the week, and after three site visits, each IMEX scholar is sent a more global evaluation and reflective electronic survey, including questions on the impact of the IMEX experience on personal competence as a teacher and educator, daily work, career, international collaborations, the scholar’s own institution and participant satisfaction with the general program format, with space to expand their answers. This report summarizes the results of the general IMEX survey, conducted in 2012 and 2013, including all scholars who had participated in the program to date (August 2013).

결과

Results

From the autumn of 2006 to the summer of 2013, IMEX organized 14 site visits (three in Utrecht, three in Montreal, three in London, three in Halifax and two in Stockholm). One Stockholm visit did not take place due to a late cancellation of some scholars for personal reasons and consequently the agreed minimum number of participants (6) was not reached. In that same period, 31 scholars had participated in at least one site visit, for a total of 121 IMEX individual visits; five scholars visited fewer than three sites and have not yet finished the program, nine went to three sites, 12 went to four sites and eight went to five sites. The group size varied from 6 (the very first week in Utrecht) to 13 (Utrecht, spring 2012).

All 29 who had completed at least three site visits were sent the anonymous overall IMEX survey. We received 22 responses (76%), six of whom had not checked the box to allow their data to be used in a publication. This report is therefore based on 16 responses (55%).

Impact of IMEX

Table 1 shows the respondents’ answers regarding the impact of IMEX on their perceptions of their career and competence. IMEX was viewed as having an impact on personal competence, career and international orientation and collaboration; less impact was reported on daily work or the respondent’s institution.

A typical comment regarding the impact on personal competence was: 

“IMEX has definitely influenced my personal competence, but it is not so easy to pinpoint it on specific knowledge or skills. It broadens your scope, makes you realize differences and similarities between (educational) cultures, realize that your own (local, national) problems and frustrations are sometimes more general and it [teaches] you a lot about other solutions and approaches. It also gives you an opportunity to learn about aspects of medical education in which you are less involved in daily practice.”

Impact on daily work was explained with comments such as the following:

“I can now speak to colleagues and other faculty with some authority about values and solutions in other countries. This is not limited to medical education but extends to health care delivery.” and “I now incorporate ideas and issues I have learned internationally into my daily work as a teacher and academic. IMEX was a very important trigger for the research I have newly embarked on which was a direct result of my first IMEX visit to Utrecht.”

The impact of the IMEX program on career is less apparent. We have noticed in our institutions that IMEX alumni often take major steps in an education career, such as accepting responsibilities as program director of undergraduate or postgraduate education, but a direct causal link with IMEX, if present, cannot easily be established. Participant comments included: 

“Somewhat useful, but limited in a formal way. However, a distinguished part of my pedagogic CV” and “I have written about my IMEX experience as part of my application for promotion to […] and it has been an important element of this application.” One respondent mentioned, “Since my involvement in the IMEX program, I have been selected as the Associate Dean for CME at [my] University. I bring a broader perspective than many of my peers to the table in discussions of issues in medical education and to my work in CME”.

International collaborations have happened to variable degrees; it does, however, seem to occur for some and it appears that there are external factors that influence the degree to which these collaborations can develop. 

“We all seem to have very busy careers at home and trans-border academic work has not happened to a substantial extent yet” and “It has been given me a new network”; however, one scholar mentioned, “I now have a regular working relationship with colleagues at X medical school and was invited to present work at a professional day they were running for staff”.

IMEX’s impact on the home institution of the scholars was explored in terms of how a hosted IMEX visit affected a much larger part of the local institutional community. 

“When you are the host for a IMEX site visit you influence and engage a lot of people around you” and “As a participant institution of IMEX we have benefited from two IMEX visits”. 

In a more general sense, 

“At X, all 5 participants have so far had a substantial impact on the faculty, as all of us still are in more or less leading positions on the medical programme”.

IMEX scholars’ views of the program features of IMEX

Table 2 shows how almost all defining features of IMEX were valued as very important and successful.

Taking an active part in local educational activities scored lowest of all features. It was not always possible to engage scholars in local teaching, which may have caused this view among the participants, but it may not be an essential outcome of the course. 

“While exposure to education is important, I feel the real value is in working with interested colleagues. Learning is after all a contextual and social activity.”

Observing education may be sufficient. “Just the possibility to see and hear teaching outside our own “bubble” was eye-opening to all the possibilities and knowledge/experience that is out there” even if the observed education is not perfect. 

“It does not have to be the successful educational sessions to observe to make them valuable, it is equally important to observe things that [give] you ideas about how to improve” and “Being in a different country changed the way I thought about my own subject and ‘made it strange' - something that is very difficult to achieve in day-to-day life. It also highlighted to me the strengths of my own curriculum which are sometimes difficult to see when you are so close to them.”

Leaving one’s own institution to have a week of protected time to reflect on education with similarly interested colleagues was highly valued.

 “The one week modules are a guarantee for putting everyday work aside” … “The most important aspect of IMEX was to allow time for reflection. It allowed [me] as well to interact with like-minded colleagues and to make friends” … “Observing education and talking to experts one-on-one are the two most important things with IMEX”.

Suggested improvements and overall view

Suggestions for improvement of the program included an addition of a US medical school to the consortium, better coordination of follow-up activities, and better organization of responsibilities for the visit at the local IMEX site, avoiding too much of an organizational burden on local IMEX participants, as at many sites, domestic IMEX scholars take responsibilities in the organization of the week.

Most participants would recommend IMEX to colleagues: 

“The IMEX experience is amazing. I would recommend it to any academic looking to expand their horizons, particularly in mid-career. The space it gave me to reflect and think about wider issues was invaluable and the unexpected spin-off was that it sparked new research ideas. A thousand thanks for this IMEX”.

논의

Discussion

Based on the past seven years of IMEX implementation and the evaluation by scholars who have completed three site visits, we believe that IMEX has lived up to its expectations. The objectives intended by the founders of the program appear to have been attained. It has been possible to sustain the organization over time and IMEX scholars are almost invariably satisfied with most site visits and most features of IMEX. We believe that we have contributed to the quality of the educational culture in the five institutions, even though we have not rigorously measured this, nor could we easily establish a causal relationship with IMEX; a more rigorous approach is needed (Armstrong & Barsion 2006). We have no doubt, however, that IMEX fits very well into a medical educator’s scholarly career development (Fincher et al. 2000; Simpson et al. 2007). 

참가자 반응

Participants spoke consistently...

of personal development, 

of broader views of medical education in other contexts, and 

of more balanced views of their own institutions. 

They also described the value of meeting and developing relationships with new international colleagues, thus enlarging their personal networks. Increasingly, the faculty development literature reports personal and professional development as an outcome of longitudinal faculty development experiences (Armstrong & Barsion 2006; Branch et al. 2009). This seems to be perceived by the IMEX scholar after some time has elapsed since their participation, suggesting that the personal development benefits reported may continue into the future.

Our initiative may also serve as an example for other schools. We have discussed the possibility of expanding IMEX to include more schools, but the inevitable consequence would be that groups would be larger or would have to split, and the current formula of having groups of scholars meet again at a next site would not be sustainable. Given logistical limitations, we cannot guarantee that the groups stay together, but almost all scholars meet their colleagues and friends again on at least one other IMEX site visit.

One regular and continuing challenge is the financing of applicants. On top of the IMEX site visit fee, scholars must travel to the site and possibly give up clinical and other income. Interested faculty members have sometimes not been able to organize the funding. One of the five institutions has generously covered travel costs for foreign scholars visiting their school and home scholars visiting other institutions. Other schools have supported IMEX scholars in various other ways. On one occasion, a scholar from a non-consortium institution requested to attend and filled a vacant slot. We have declined requests to participate by medical educators from other countries so as not to dilute the institutional collaboration. However, we recognize that broader involvement may support the sustainability of the program.

Our data collection has limitations. Not all alumni responded and not all questions were answered. As our survey was anonymous, we could not follow the initial request with a targeted reminder. Moreover, as mentioned previously, we did not attempt to validate the perceived impact on personal career development, but believe that the personal feelings of IMEX alumni about this have worth in themselves.

IMEX has clearly shown its added value as a new component to the portfolio of faculty development activities. An international dimension in the development of medical educators broadens their perspective on medical education in way that adds to most regular faculty development programs.

Faculty development through international exchange: The IMEX initiative.

A model for linkage between health professions education and health: FAIMER international faculty development initiatives

WILLIAM BURDICK1, ELIANA AMARAL2, HENRY CAMPOS3 & JOHN NORCINI1

1FAIMER, USA, 2State University of Campinas/UNICAMP, Brazil, 3Universidade Federal do Ceara´ , Brazil

도입

Introduction

교수개발과 지역사회 보건증진을 연결시키는 것이 보건의료인력교육자와 연구자 모두에게 중요하다. 개개인 차원, 조직 차원에서 보건의료인력 교육을 통한 보건증진이 가능할 수 있겠지만, 이런 것을 서로 연결시켜주는 문헌은 제한적이다. 한편으로는 건강결정인자로 교육 외에도 영양, 물 안전, 위생과 같은 더 강력한 요인들이 있기 때문일 것이다. 

Linking faculty development to improvement of community health is of particular interest to health professions educators and researchers (Burdick et al. 2007; Haan et al. 2008). While individuals and institutions engaged in health professions education have the potential to improve health (Boelen 1999; Frenk et al. 2010), limited literature connects capacity building in education with improvements in health (Burdick et al. 2007). In part, this is because there are many stronger determinants of health, such as nutrition, water safety, and sanitation (Wilkinson & Marmot 2003), than the education of doctors and nurses. Understanding the mechanism by which faculty development may promote development of socially accountable institutions and improve health can be useful for improving this connection and evaluating program effectiveness. In this article, we present a testable model for the link between faculty development and improvement in health, and offer an example of that model.

개개인 차원의 역량 강화를 위해서는 의미있는 학습 경험을 통해 새로운 지식을 얻고, 새로운 분야에 접근할 수 있는 기회가 있어야 한다. 시스템 차원의 역량 강화는 개개인의 역량 강화를 넘어서는 것이며, 이들간의 네트워크를 강화하는 것이 중요하다. 이를 위해서는 다음과 같은 것이 필요하다.

Individual capacity building requires participation in a meaningful learning experience, opportunity to apply new knowledge, and opportunities for advancement in the new field (Nchinda 2002). System capacity building goes beyond development of the individual to strengthening collaborating organizations and the web that connects them. It requires...

• strengthening domain knowledge and communication skills of members of the system, 
• plus interactive, or relational, skills such as creating a shared vision, 
• organizational capacity such as leadership, and management, and 
• programmatic capacity such as the ability to develop projects aligned with community needs (Foster-Fishman et al. 2001). 

개개인의 역량을 강화하는 데 있어서 '프로젝트'를 하는 것은 중요한데, 이는 새롭게 배운 리더십/관리 기술 등을 실제로 적용시킬 수 있는 기회이기 때문이다.

Projects are an important part of the individual capacity model since they provide the opportunity for authentic application of new skills, particularly leadership and management skills. (Gusic et al. 2010; Burdick et al. (in press)).

사회적 네트워크를 개발하고 활용하는 것은 시스템 차원의 역량 강화에 중요한 것이다. 또한 교육 기관의 사회적 책무를 강화하는 쪽으로 이끄는 역할을 하는데 중요하다. community of health professions educator를 만든다는 중간단계 목표는 장기적 목표인 'field leadership'을 강화하는데 필요하다. 협동, 지식확산과 같은 Field leadership은 보건의료인력교육 영역을 더욱 강화할 것이다. 교육 분야의 다양한 영역이 이에 기여할 수 있다.

Development and use of social networks is a key element of system capacity building (Culbertson 1981; Bolam et al. 2005; Cross et al. 2006; Moses et al. 2009) and represents an important link in the mechanism leading to enhanced social accountability of education institutions. This intermediate goal of developing a community of health professions educators is a precursor to achieving the longer term goal of building “field leadership” (Mouradian & Huebner 2007). Field leadership skills like collaboration and knowledge diffusion strengthen the health professions education field. A dynamic field of education then can contribute to improvement of the health of communities through...

• robust peer review, 
• high quality research to ascertain health needs, 
• implementation of effective learning and assessment methods, 
• advocacy for academic promotion criteria attuned to scholarship in education and community health, and 
• promotion of rigorous accreditation systems that consider social accountability (Boelen 2004).

The FAIMER Institute is based in the United States, with an international distribution of Fellows. There are five FAIMER Regional Institutes: three based in India, serving mainly Indian faculty with a small number from surrounding countries; one in South Africa, serving southern Africa; and one in Brazil, conducted in Portuguese and serving Brazilian faculty. The US-based program was started in 2001; the others in 2005–2008 (Burdick et al. 2006, 2010).

FAIMER 교육 프로그램은 여러 국가를 아우르는 접근법을 활용한다는 점이 독특하며, 개발도상국의 다양한 보건의료인력 교육을 강조하고 있다. 또한 리더십을 키우고, 보건의료인력교육자의 커뮤니티를 만들기 위해 노력하고 있다. 이러한 노력은, 대부분의 국제적 보건의료에 대한 자원투자가 질병 예방과 치료 프로그램에 집중되어 있는 것에 상보적인 것이라 할 수 있으며, 보건시스템의 의료인력 양성에 힘을 쏟아야 한다는 여러 저자들의 의견과도 부합하는 것이다.

The FAIMER education program is unusual in its transnational approach and its emphasis on a mix of health professions faculty from resource limited countries, with an explicit goal of improving leadership skills and creating a global community of health professions educators. This emphasis is complementary to the approach of most current international health resource investments, which are devoted to priority disease prevention and treatment programs, and consistent with an increasing number of authors recommending funding focused specifically on capacity building of human resources in the health system (Drager et al. 2006; McCourt & Awases 2007; Awofeso et al. 2008; Global Health Workforce Alliance 2008).

의과대학과 다른 보건의료인력을 양성하는 대학이 갖는 사회적 책무성은 점차 더 커지고 있으며, 사회적 요구에 따라서 교육 시스템을 개선시킬 필요가 있다. 

There is greater recognition of the social responsibility of medical schools and other health professions schools to re-orient and improve their education systems to more directly address societal needs (Boelen & Woollard 2010). We describe a model for faculty development in health professions education with individual and system capacity building that has the potential to lead to improvements in health, and provide a case study of the Brazil FAIMER Regional Institute (FRI) in its application.

모델

The model

우리의 교수개발 모델의 핵심 목표는 다음과 같다.

In our model of faculty development, key goals are ....

(1) enhanced knowledge of education methods, 

(2) strengthened leadership and management skills, and 

(3) creation of a network of educators, leading to a strengthened field of health professions education. 

An additional element, demonstrated by the example of the Brazil FRI, is the engagement of the public sector (Figure 1).

여러 주제별 워크숍을 통한 교육방법에 대한 지식과 리더십 스킬은 각 연수생 본국의 조직에서 역량 강화를 위한 혁신 프로젝트에 적용하도록 했다. 개인과 조직의 역량을 강화하기 위해서는 개개인의 네트워크가 필요하고, 조직간 정보를 공유하고 협력하는 것이 필요하다. 이 네트워크의 중요한 특징은...

Knowledge of education methods, developed through topical workshops, and leadership skills applied to the development of an education innovation project, lead to individual and institutional capacity building. Leveraging individual and institutional capacity building requires a network of individuals and institutions sharing information and collaborating. An important and codified manifestation of this network is...

a strong field of health professions education, with robust peer review of new knowledge, collaborative research, shared advocacy, and mentorship and support for individuals. 

In addition to the people who form the network,...

a field has its own language, values, and norms, projected in the form of a membership organization, 

periodic plenary meetings, and 

often a standardized tool for communication, such as a journal and website (Fraser & Greenhalgh 2001; Mouradian & Huebner 2007).

공공부문의 협조 

Public sector engagement

Engagement of the public sector is a critical element in the success of health improvement initiatives (Levine 2007). The capacity to scale up these interventions has many enabling features, but strengthening the health system is one in which government can play a key role (Mangham & Hanson 2010). Aligning faculty development efforts with public initiatives is therefore an important concept in leveraging improvements in education.

An important element of our approach has been to try to involve relevant government agencies. In India, the Medical Council of India has coordinated faculty development plans by building upon existing FRI and using a database of FAIMER Fellows in the country. In Brazil, (Appendix) the Secretariat of Labor Management and Health Education (SGTES – Secretaria de Gestão do Ensino e Trabalho e Educação em Saúde) participated in the initial planning meetings for the Brazil FRI, and provides the majority of the funding.

사회적 네트워크 구축

Social network development

The design of FAIMER education programs is highly interactive to enhance learning (Michael 2006), and intentionally creates and reinforces the bonds between Fellows by a variety of high-engagement methods. These include...

• team building and group dynamics exercises, 
• intensive interaction and dialog during the residential sessions, 
• evening “learning circles” during which personal stories are shared (Baldwin 1998; Danzig 1999; Wheatley 2002), 
• continuous emphasis on development of a “safe” learning environment, 
• creation of online discussion leader teams, 
• telephone contact every several weeks during the non-residential sessions, and 
• encouragement of “social presence” on the listserv (Kreijns et al. 2004).

Our model proposes that an active community of educators can lead to several outcomes that can then lead to a field of health professions education with greater social accountability. The potential outcomes of a network of educators include a robust system for peer review and dissemination of new discoveries, personal and professional mentoring, collaboration, and policy advocacy for improved accreditation systems. The resulting field could be characterized by educators responsive to local needs through aligned curricula, health worker training, and community education. Other indicators could be a path for promotion for work in education, schools with high-quality research, and application of new knowledge and skills to education and healthcare practice.

FAIMER Fellows from other programs reported that the impact of their project on their institution was significant. 

• More than half of the 49 responding Fellows from the Philadelphia FAIMER Institute identified changes related to increased quality of teaching and collaboration in education when asked to identify changes in their schools or communities resulting from their projects. 
• In addition, 41% responded that there is more faculty interest in research in education. Other frequent changes cited by one-third or more of respondents included improvements in assessment and student performance. 
• One-third noted that the curriculum is better aligned with community health needs. 
• By contrast, only one-tenth to one-fifth reported increases in knowledge in rural healthcare, working in community settings, training of community health workers or community service among students. 
• Only 4% responded that their project resulted in better health (Burdick et al. (in press)).

리더십과 관리기술 향상

Enhanced leadership and management skills

Leadership skills are developed through conceptual discussions that are then applied to Fellows’ projects. Myers–Briggs Temperament Index (MBTI) is used as a way for Fellows to better understand their natural tendencies in professional interactions and leadership situations. A group exercise of “crossing the river” tangibly demonstrates leadership and group decision-making dynamics. Conflict management and change management concepts are presented using authentic role plays gleaned from previous Fellows’ experiences. A strong emphasis is placed on “appreciative leadership” values, and involvement of stakeholders.

Evidence from the first 5 years of the Philadelphia FAIMER Institute indicates that ..

• our education intervention is achieving its short-term goal of enhanced leadership and management skills. 
• When asked in an interview to describe if and how they had applied concepts and skills learned at the FAIMER Institute to their work, 98% of the Fellows mentioned at least one leadership skill or method, making this the most frequently mentioned category of skill used. 
• Within the leadership/management domain, the specific skills or tools mentioned included appreciative inquiry and/or appreciative leadership by 49%, conflict management and team building/group process each by 40%, use of the Myers–Briggs Type Indicator for understanding one's own leadership style and Gantt charting each by 38%, and project management tools in general by 29% (Burdick et al. 2010).

교육과 평가 능력 향상

Improved teaching and assessment

Workshops on large group, small group, and individual teaching discuss basic concepts of adult learning, and then ask Fellows to apply them to examples from their own teaching experiences. Additional sessions on student assessment, performance assessment, and standard setting reinforce the connection between teaching and assessment.

In a study from the Philadelphia FAIMER Institute, there were significant increases between Fellows’ reported “before and after” data about perceptions of the importance of, and their own competence in, all eight curriculum theme areas in Session 1 and all five curriculum theme areas in Session 3. In all cases, the effect sizes ranged between 1.3 and 2.7 (p < 0.0001) (Burdick et al. 2010).

사회적 네트워크 구축

Social network development

The program begins with a series of structured exercises intended to create bonds between participants. Fellows interview several others, asking for one answer each time to inquire about their profession role, a personal aim for the program, and one personal fact. They then introduce each other to the group. After MBTI assessment, and “crossing the river,” they debrief with observers on the interpersonal and group dynamics that led to successes and frustrations in completing the task. In addition to extensive interaction during the daytime portion of the residential component, Fellows meet in the evening several times during the program in “learning circles,” in which the social bonds are strengthened through shared personal stories (Baldwin 1998; Danzig 1999; Wheatley 2002). During the online intersession period, Fellows interact with each other and the faculty advisors through e-learning modules, periodic conference calls with a mentoring group, and social exchanges on a Listserv. When Fellows return for the second residential session, a structured process is used to introduce them to the first-year Fellows.

Discussion

The FAIMER faculty development model of building a social network, strengthening leadership and management skills through an authentic project, enhancing knowledge of education methods, and engagement of the public sector has potential to change education in ways that lead to improved health. The Brazil FRI represents an example of how that model is implemented.

The model is a manifestation of a theory of change, or program theory, and as such can provide a framework for evaluation (Sridharan & Nakaima 2011). Demonstrating gains in health as a result in education improvement is difficult due to the long lead time and myriad of other social variables. Short-term and intermediate outcomes in the model, however, may be just as important to identify. Evidence for this model suggests that an effective learning environment has been created, with significant gains in self-reported knowledge and skill. Improved teaching and assessment methods, as well as the skills to diffuse this knowledge to others through the network of educators, should lead to stronger health professions units in institutions. This may, in turn, lead to more robust quality improvement systems such as feedback collection, and curriculum evaluation, and has the potential to improve education throughout the institution.

Evidence from the Brazil FRI and other FAIMER Institutes also suggests that locally authentic education innovation projects are being completed, and that a portion of them have potential to show direct effects on health. Some projects may directly lead to improvements in health when they include student or faculty led patient education initiatives, health surveillance projects, or community-based education interventions that increase access to care. Achievement of short-term outcomes may provide necessary (but not sufficient) support for validity of the model.

Intermediate outcomes provide further evidence. Reports from Fellows suggest that a strong, meaningful network of educators is being created locally and globally. It is used by Fellows for diffusion of knowledge and resources, and as a source of professional and personal support. In addition to the volume of intra-network communication, the growth and development of regional organizations dedicated to health professions education is an indicator for the successful growth of health professions networks, one of the central intermediate outcomes of the model (Sood 2008).

FAIMER education programs address a demand for pro-active engagement of academic institutions in building sustainable health systems that arises from several factors. 

• First, academic institutions play a vital role in production and maintenance of the skilled workforce expected to meet the needs of the population (Boelen 2000; WHO 2006). 
• Second, global focus on strengthening health systems, efforts to reinforce policies supporting primary healthcare, and increasing demand for universal coverage of health systems highlight the need to develop effective leadership to promote successful and sustainable innovation in academic institutions (WHO 2008, 2010; Reich & Takemi 2009). 
• Finally, “third generation” education reforms that use transformative learning and leadership development to produce enlightened change agents require formidable innovations in the education pipeline (Frenk et al. 2010). Individual faculty and the education systems in which they work must be equipped through high-quality faculty development to be able to initiate and sustain these innovations.

As more faculty are oriented to the social mission, the culture of the school is changed (Langdon & Wiik 2010), with values, norms, language, and practices that create a learning environment that emphasizes the community as well as the individual patient. Explicit development of a theory of change for how their innovation project may result in a long-term outcome of improved community health is one way to help align faculty and their school with the social mission of health professions education. The resulting socially oriented learning environment may help create a new professional, highly qualified, aware, and knowledgeable of the social determinants of health, accepting their role as health advocate, and helping to reduce the gap between health needs and the care provided.

Our model of faculty development, with emphasis on active learning, leadership, use of projects, social network development, and engagement with the public sector, may provide a testable framework for connecting improvement in health professions education with improvement in health.

A model for linkage between health professions education and health: FAIMER international faculty developmentinitiatives.

How Important Is Money as a Reward for Teaching?

Antoinette S. Peters, PhD, Kathleen N. Schnaidt, Kara Zivin, PhD,

Sheryl L. Rifas-Shiman, MPH, and Harvey P. Katz, MD

배경

현재, 대부분의 미국 의과대학은 외래에서 이뤄지는 일차진료 기반 임상실습을 진행하고 있다. 그럼에도 불구하고 일차의료의사는 이같은 학생 교육에 대해서 - 완전히 못해먹겠다는 수준은 아니더라도- 상당한 부담을 느끼고 있다. 따라서 지속적으로 본과3학년 학생에게 적절한 학습경험을 심어줄 수 있는 일차의료의를 찾아서 모집할 필요가 있다.

Currently, almost all U.S. medical schools offer office-based primary care clerkships. Yet, primary care doctors are under such great pressure for productivity that teaching becomes a burden, if not a downright impossibility. Thus, there is an ongoing need to identify and recruit primary care physicians who can provide a sound educational experience for third-year medical students.

교육과 임상 생산성간의 긴장관계는 어떻게 동기부여를 하고 어떻게 보상을 줄 것인지에 대한 관점을 지배하고 있으며, 학교는 교육에 대해 "돈을 주는" 방법을 사용함으로서 학생 교육때문에 감소하는 임상수입을 경제적으로 보상해주고자 하고 있다. 비록 의과대학에서는 교육에 참여하는 일차의료의에게 보상을 해주는 경우가 많긴 하지만, 의과대학과의 관계를 보여주는 현판을 붙여준다거나, 무료 CME프로그램을 제공한다거나 하는 것 중에서 임상 수입을 대체할만큼 충분한 것은 거의 없다.

This tension between teaching and clinical productivity has led to changes in perspective on motivators and rewards for teaching, and to recommendations that schools pay “hard” money for teaching 1 to relieve faculty from the burden of financially supporting themselves through clinical dollars.2 Although medical schools commonly reward primary care physicians who teach in their offices with academic appointments, plaques identifying their relationship to the medical school, and access to free CME programs, few have been able to pay enough for teaching to replace clinical income.3,4

지금까지의 연구를 살펴보면, teaching practice는 nonteaching practice보다 비용이 30~40%정도 더 들어가며, 학생이 있으면 환자를 두 배 정도 더 길게 보게 된다. 따라서 하루에 보는 환자 수가 줄거나, 의사는 더 오랜 시간 진료를 하게 된다. 따라서 교육의 비용은 개별 의사가 감당하게 되는 것이다. 그럼에도 불구하고 많은 의사들은 교육을 통해 개인적 만족을 얻는다고 보고하고 있으며, 돈의 가치보다 교육의 기쁨을 더 높은 가치로 평가하기도 하기 때문에, 우리는 교육에 대한 보상으로서의 금전적 지급이 과연 필요한지 생각해볼 필요가 있다.

Research has shown that teaching practices cost between 30% and 40% more to operate than nonteaching practices,4–6 patient encounters are approximately twice as long when a student is present,6,7 and either fewer patients are seen and/or the physician’s day is extended.4 Therefore, both the practices and the individual physicians absorb the costs of teaching. Despite this, because many physicians report that they teach for personal satisfaction and rate the value of money lower than the pleasure of teaching,3,7–11 we must ask whether payment for teaching is necessary.

동기부여를 하는 요인과 보상이 갖는 효과는 복잡하다. 심리학자들은 외적 보상이 과연 필요한가, 그것이 내적 동기를 오히려 손상시키는 것이 아닌지, 만약 필요하다면 얼마나 즉각적으로 또는 자주 또는 직접적으로 지급되어야 효과적인지를 연구해왔다. 대표적인 연구를 보면 Herzberg는 금전적 인센티브의 효과성을 연구한 바 있는데, 직무만족도와 동기부여는 직무불만족을 야기하는 요인들과 분리되어 있으며 별개의 것(separate and distinct)한 것이라고 밝혔다. 동기부여와 만족을 유도하는 Needs는 내재적인 것이며, "인간의 고유한 특성으로, 성취를 달성하고, 이러한 성취를 통해서 심리적 성장을 경험하는" 것이라 했다. 불만족을 야기하는 것은 "직무 외적인(extrinsic to the job)"것으로 "근무조건, 봉급, 직위, 안정성" 등이라고 하였다.

The effect of motivators and rewards is complex. Psychologists have asked whether extrinsic reward is necessary at all, whether it undermines intrinsic rewards,12 and, if it is needed, how immediate, frequent, and direct it must be to be effective.13 In a seminal article on how to motivate employees, Herzberg 14 explored the effectiveness of monetary incentives. He concluded that job satisfaction and motivation stem from needs “separate and distinct” from those leading to job dissatisfaction. Needs leading to motivation and satisfaction relate to an intrinsic and “unique human characteristic, the ability to achieve and, through achievement, to experience psychological growth.” Those leading to dissatisfaction are “extrinsic to the job”—negative “working conditions, salary, status and security.”

오늘날의 일차의료는 이 두 가지를 모두 필요로 한다. 환자 및 학생을 위한 폭넓은 정보와 긴밀한 관계를 필요로 하면서, 더 많은 시간 근무하여 환자를 봐야 한다. 따라서 일차의료의들이 교육의 만족과 보상의 요구 사이의 균형을 어떻게 맞추는지 볼 필요가 있다.

Today’s practice of primary care involves both sets of needs: a breadth of content and close relationships with patients and students (achievement and recognition), but also long work hours during which one must see many patients to meet the demands of insurers.15 It is important, then, to understand the complex nature of how primary care physicians balance the need for satisfaction of teaching with the need for compensation.

하버드 의과대학은 지난 10년간 Longitudinal한 9개월짜리 일차의료 임상실습을 도입해서 진행해왔다. 1997년 이것이 처음 도입되었을 때, 학생을 지도해주는 의사에게 600$를 지급하였다. 그러나 4시간짜리 세션을 27번 하는 것을 감안하면 이것은 그 시간의 비용에 대한 보상 치고는 보잘것없는 것이었다. 또한 임상실습을 담당하고 있는 입장에서 항상 지도해줄 의사를 모집하는 것은 쉬운 일이 아니었고, 그래서 보상금을 올려줌으로서 지도 의사들의 재정 부담을 덜어주고, 우리 입장에서의 모집 부담을 줄일 수 있을 것을 기대했다. 2003년에는 900달러, 2004년에는 2500달러로 높였다.

Harvard Medical School has offered a longitudinal, nine-month primary care clerkship for the past 10 years.16 From its inception in 1997, the clerkship paid preceptors a $600 stipend. However, for 27 four-hour sessions, this was more a token of appreciation than compensation for lost revenue. Because those of us in charge of the clerkship have always found it difficult to recruit enough preceptors to teach between 120 and 150 students each year, we hoped that raising the amount of the stipend would ease the financial burden for preceptors and, consequently, help us retain them as faculty. With cooperation from our deans, we raised the stipend to $900 in 2003 and then to $2,500 in 2004.

이 연구에서, 보상금의 증액과 faculty의 retention사이의 관계를 보고자 하였으며, 추가적으로 이 faculty들을 대상으로 (1)외적 보상 및 동기부여와 내적 보상 및 동기부여의 가치, (2)직접 받는 것과 간접적으로 받는 것의 가치를 보고자 했다.

In this study, we examine the association between the rise in stipend and retention of faculty. Additionally, we explore faculty members’ perceptions of the relative value of (1) an external reward or motivator (the stipend) and internal rewards and motivators, and (2) receiving the stipend directly or indirectly.

방법

Analyses

Because we informed faculty of the stipend upon recruiting them, and because we paid them at the end of the clerkship, we assume that the stipend is both a motivator and a reward. Therefore, we computed the annual retention rates and the average retention rate for each stipend period (i.e., when the stipend was $600, $900, and then $2,500) as well as in the year after the rise in stipend (i.e., when the stipend changed from $600 to $900, and again when it changed from $900 to $2,500). We examined the relationship between change in stipend and the proportion of faculty we lost each year either because they were unavailable or they declined to teach versus the proportion of those who were willing to teach, whether or not they were matched to a student. Then, on the basis of physicians’ availability to teach, we conducted logistic regressions to estimate the odds of returning after each rise in stipend using general estimating equations to account for correlation within physician.18,19

 Further, we examined the frequency of rankings as well as the mean rank-order of factors involved in decisions to continue teaching and sources of satisfaction with teaching; we conducted t tests to determine the relationship between these rankings to teaching status (declined versus retained), and directness of payment (direct versus indirect). All statistical tests were conducted with a significance level of P < .05.

결과 : 

retention rate는 2006년에 91%로 높았고, 2000년에 69%로 낮았다. faculty들은 가장 적은 보상이 주어졌던 시기보다 가장 많은 보상이 주어졌던 시기에 2.66배 더 많이 교육을 지속하고자 했으며, 직접적으로 보상을 받은 경우에 더 교육을 지속하고자 했다. 응답한 170명의 faculty중 8%만이 교육을 지속하는 요인으로 있어서 보상금이 가장 중요하다고 응답했으며, 만족을 주는 근원 중 1순위로 보상금을 뽑은 의사는 아무도 없었다. 그러나 73%는 좋은 학생을 받는 것이 교육을 지속하는 첫 번째 요인이라고 응답했고, 82%는 이것이 만족의 제1 요인이라고 응답했다.

Results: Retention rates varied from a high of 91% in 2006 to a low of 69% in 2000. Faculty were 2.66 times more likely (P < .0001) to return to teach in the highest pay period than the lowest, and faculty receiving direct payment were more likely to continue teaching than those receiving it indirectly. Only 8% of the 170 responding faculty ranked receiving the stipend as the most important factor in their continuing to teach; no one ranked it first as a source of satisfaction. However, 73% ranked having a good student first as a factor in continuing to teach; 82% ranked it first as a source of satisfaction.

결론 : 

보상금을 올리는 것이 retention을 높이는 것과 상관관계가 있었으나, 교육을 하는것에 대한 동기부여 요인으로서 보상금은 낮은 순위에 있었다. 

Conclusion: Raising stipends was associated with increased retention, although faculty ranked stipend low in terms of what motivates them to continue teaching.

How important is money as a reward for teaching?

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

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

A Meta-Analysis of the Five-Factor Model of Personality and Academic Performance

Arthur E. Poropat

Griffith University

This article reports a meta-analysis of personality–academic performance relationships, based on the 5-factor model, in which cumulative sample sizes ranged to over 70,000. Most analyzed studies came from the tertiary level of education, but there were similar aggregate samples from secondary and tertiary education. There was a comparatively smaller sample derived from studies at the primary level. 

다섯 가지 특징 

외향성(Extroversion vs. Introversion), 

개방성(Openness vs. Non-openness), 

동조성(Agreeableness vs. Antagonism), 

성실성(Conscientiousness vs. Undirectedness), 

신경성(Neuroticism vs. Emotional Stability)

다섯 가지 중 학업수행능력과 유의미하게 관련이 있는 것은 동조성, 성실성, 개방성이었다.

Academic performance was found to correlate significantly with Agreeableness, Conscientiousness, and Openness. Where tested, correlations between Conscientiousness and academic performance were largely independent of intelligence. 

When secondary academic performance was controlled for, Conscientiousness added as much to the prediction of tertiary academic performance as did intelligence. Strong evidence was found for moderators of correlations. 

Academic level (primary, secondary, or tertiary), average age of participant, and the interaction between academic level and age significantly moderated correlations with academic performance. Possible explanations for these moderator effects are discussed, and recommendations for future research are provided.

Conclusion

In their review, De Raad and Schouwenburg (1996) concluded that “personality usually comes at the bottom of the list of theorizing” (p. 328) about learning and education. The results of this meta-analysis indicate that personality should take a more prominent place in future theories of academic performance and not merely as an adjunct to intelligence. This research has demonstrated that the optimism of earlier researchers on academic performance–personality relationships was justified; personality is definitely associated with academic performance. At the same time, the results of this research have provided further evidence of the validity of the lexical hypothesis and have established a firm basis for viewing personality as an important component of students’ willingness to perform. And, just as with work performance, Conscientiousness has the strongest association with academic performance of all the FFM dimensions; its association with academic performance rivaled that of intelligence except in primary education. Yet the complications highlighted by the moderator analyses indicate that the relationship between personality and academic performance must be understood as a complex phenomenon in its own right.

Future considerations of individual differences with respect to academic performance will need to consider not only the g factor of intelligence but also the w factor of Conscientiousness. However, the strength of the various moderators examined in this meta-analysis shows that, although it can be stated that personality is related to academic performance, any such statement must be subject to qualifications relating to academic level, age, and the interaction between these variables, and most likely also to range restriction. The degree of heterogeneity identified within the samples indicates that there are likely to be further substantial moderators to be identified. Although the role of personality in academic performance may be both statistically and practically significant, it is also subtle and complex. As such, it is will require much further exploration.

A meta-analysis of the five-factor model of personality and academic performance.

Can we improve on how we select medical students?

Patricia Hughes, MSc FRCPsych

Admissions Office, Hunter Wing, St George's Hospital Medical School, London SW17 0RE, UK

E-mail: p.hughes@shgms.ac.uk

합당한 의과대학 입학정책을 운영하는 것은 좋은 의사가 될 잠재력을 가진 사람을 선발함으로서 사회에 대한 타당성(fair)을 갖춰야 하며, 또한 지원자에 대한 공정함(fair)을 갖춰야 한다. 선발은 엄밀한 과학은 아니지만, 모든 측면에서 최선을 다하기 위해 활용가능한 근거를 최대한 활용해야 한다. 단순한 학업적 성취 외에도 더 넓은 범위의 준거를 활용해야 한다는 것에 대한 폭넓은 동의가 있으나, 현실적으로 많은 의과대학이 다른 고려사항보다도 입학 전 학업성적을 가장 중요한 준거로 삼는다. 

그러나 학교 성적을 지적 역량의 척도로 활용하는 것에 대한 단점이 있어서, 대표적으로 A학점을 받는 것에 가장 중요하게 작용하는 요인이 사회적 계층이며, 개인의 능력과는 무관하다는 연구가 있다. 또한 의과대학생이 되려고 하는 학생들이 과학 과목에 집중하는 이유가 physical sciences 부분에서 인문 과목보다 더 좋은 점수를 받기 쉽기 때문이다. 시험 결과만이 타당하고 신되도 있는 자료라는 것은 '매력적이지만 오류가 많은' 신념이다. 우리는 모든 선발 도구들이 주관적 판단에 의존하고 있다는 것을 명심해야 하며, 각각의 도구들은 논리, 공정함, 공공의 검토(reason, fairness and public scrutiny)라는 규칙을 따라야 한다. 그러나 우리가 비인지적 준거를 고려하자고 하는 순간 의학의 여러 전문과목들은 다양한 skill을 필요로 하며, 따라서 그 준거들이 너무 협소해서는 안된다는 타당한 우려를 갖게 된다. 또한 우리가 비인지적 특징을 평가에 포함시키고자 한다면, 그렇게 이루어진 평가가 몇 년이 지난 후에도 개인의 특성을 잘 예측할 것이라는 확신을 갖고 싶어한다.

Getting the right policy for admission to medical school is a balancing act: be fair to society by choosing people with the potential to be good doctors; and be fair to the applicants—that diverse group of people who for many reasons want to set out on the long road to a medical career. Selection is not an exact science but we must use what evidence we have to ensure that we do our best by all concerned. There is widespread agreement that we should select future doctors on wider criteria than scores of academic success1, 2, though in practice many medical schools have valued pre-admission academic scores at the expense of other considerations3. There are recognized drawbacks to the use of school exam performance even as a measure of intellectual competence. One study has shown that a major causal determinant of A level results is social class, independent of ability4, and some would-be medical students elect to focus on sciences for their school leaving exams because very high marks are more easily achieved in the physical sciences than in the humanities5. The conviction that only exam results give valid and reliable data has been trenchantly dismissed as a ‘seductive but fallacious’ belief in the precision of quantitative tests6. We are reminded that all selective instruments depend on subjective judgments and each must be accountable to the rules of reason, fairness and public scrutiny7. However, if we decide to consider non-cognitive criteria, a legitimate concern is that the many specialties of medicine need diverse skills and they must not be too narrow. We also want to be reassured, if we include noncognitive characteristics, that we can assess them reliably and that such evaluation can predict personal character over years of practice.

의사에게 필요한 skill과 인성의 범위는 넓지만, 여전히 어떤 의사에게나 요구되는 특징이 있다. 충분한 지적 능력 외에도 정직성, 진실성, 양심 등이 좋은 진료의 중심에 있다. 도움을 주고자 하는 마음과 협력하려는 자세(Helpfulness and willingness to cooperate) 역시 중요하며, 환자들은 대인관계기술이나 공감능력이 뛰어난 의사를 좋아한다. 전문직으로서 개개인의 안녕(welfare)를 잘 유지하는 것 역시 중요하다. 의사들은 다른 직종보다 알콜중독, 약물남용, 자살 등에 취약하다. 탈진(burnout)역시 흔히 일어나는 일이며 이는 개인 뿐만 아니라 동료, 환자가 받게 되는 서비스의 질에도 큰 비용을 수반하는 것이다. 정신적으로 취약한 의사를 잘 지원해 주는 것이 하나의 답이 될 수 있을 것이지만, 더 중요한 것은 스트레스에 잘 대처할 수 있는 능력을 가진 사람을 애초에 뽑는 것일 것이다.

While we need to maintain diversity of skills and personality, there are some characteristics which we demand in any doctor. Enough intellectual ability to do the job, plus honesty, integrity and conscientiousness, must be at the heart of good practice8. Helpfulness and willingness to cooperate come close behind8, while patients give high priority to interpersonal skills and empathy2. The personal welfare of the profession is another consideration9. Doctors are more vulnerable than comparable professional groups to alcoholism, drug abuse and suicide10, 11. Burnout is well recognized, and has a high cost for the individual, for colleagues and for the quality of service that patients get12. One answer may be better support for psychologically vulnerable doctors12, 13 (together with improved working conditions for all doctors), but perhaps we should try to evaluate ability to deal with stress right from the start.

인성은 성년 이후에도 안정적으로 유지되는 특성인가?

ARE PERSONALITY CHARACTERISTICS STABLE OVER ADULT LIFE?

만약 우리가 의과대학생에게 원하는 인성을 찾고자 한다면, 이것이 과연 미래의 인성에 대해서 확실히 말해줄 수 있다는 자신감을 가질 수 있을까? 의과대학생과 이들을 15~30년간 추적한 연구에 따르면 middle age에 정신적으로 건강했던 의사들은 학생때에도 높은 자존감을 유지하고 있었고, 삶에 대해 열린/유연한 자세를 가지고 있었으며, 부모와 따뜻한 관계를 영유하고 있었고, 불안, 우울이 적었고 스트레스 상황에서 받는 화(anger)도 낮았다. 

If we seek to identify the personal characteristics we want in a medical student, can we have any confidence that they tell us anything about future personality or adjustment? Studies that assessed medical undergraduates and followed them up for between 15-30 years12, 14, 15 indicate that doctors who are psychologically well in middle age had good self esteem as students, had an open, flexible approach to life, enjoyed a warm relationship with their parents, and had little anxiety and depression and low anger under stress. 

반면, 후에 중년에 약물 오용, 자살, 탈진 등에 취약했던 의사들은 학생 때 역시 유의미하게 정신건강이 좋지 않았으며, 장기 연구에서 6년~45년의 간격을 두고 재평가(retest)를 했을 때 높은 test-retest correlation을 나타냈다. 이러한 열과는 인성의 연속적 특성이 행복하든 불행하든, 부유하든 가난하든 성년이 되어서도 유지되는 안정성(stable tendency)을 보임을 알려준다.

In contrast, doctors vulnerable to later substance abuse, to suicide and to burnout in middle age had significantly poorer measures of psychological health as undergraduates. Other long-term studies of stability of personality characteristics have shown that personality traits exhibit high test-retest correlations over intervals of 6 to 45 years16, 17, 18, 19. These findings signify a substantial continuity of personality disposition in adulthood, suggesting a stable tendency to be either happy or unhappy, well or poorly adjusted.

미래에 직무역량을 예측해주는 요인은 무엇인가?

WHAT FACTORS GENERALLY PREDICT FUTURE JOB PERFORMANCE?

의학과 의학 외 분야에서 모두 이런 것과 관련된 연구가 있다. 이러한 연구에 많은 돈을 투자한 산업계에서 유용한 정보들을 확인할 수 있다. 평균적으로 가장 생산성이 옾은 사람은 평균보다 40%쯤 더 잘벌고, 가장 나쁜 사람은 40%쯤 덜 번다는 결과를 보여주고 있다. 그런데 이것이 의학 분야와 많이 다를까? 주위를 둘러보면 최신의 지식을 갈고닦는 의사가 있고, 이런 것은 거의 하지 않는 의사가 있다. 이것이 유일한 criteria는 될 수 없지만 중요한 것임엔 틀림없다. 

There is relevant research both within medicine and outside it. Useful information comes from industry, where serious money has gone into finding out what makes a good professional20. They measure outcome in hard cash and find that the most productive people are about 40% better than average, while the least are 40% worse than average21. Is this too different from medicine to be relevant? Look around: we all know who gets the work done and keeps up to date, and who slips through life doing the minimum. These are not the only criteria for a decent doctor but they matter. 

복잡한 직무에 있어서 가장 훌륭한 예측인자는 mental ability에 대한 몇 가지 척도와 IQ이며, 더 높은 자리로 올라갈수록 IQ가 더 중요하다는 것이 지속적으로 나타나는 근거이다. 가장 높은 관리자 수준에서 전체 수행편차 중 70%가 이 것(IQ)때문이다. 따라서 높은 IQ가 중요하다는 것을 봤을 때 이것을 근거로 선발하는 것은 옳다고 할 수 있다. 예측력은 다른 몇 가지 요인을 추가하면 더욱 향상된다. 

There is consistent evidence that, for work involving complex tasks, the best predictor of effectiveness is some measure of mental ability or IQ, and the higher you go up the professional scale the more IQ matters. At the highest managerial level it accounts for almost 70% of performance variability22. So in demanding evidence of high IQ (even in the form of exam results) we have got something right. Predictability can be improved by including some measure of other factors. 

더 추가해야 할, 지속적으로 확인되는 요인은 '진실성(integrity)'와 성실성(conscientiousness)이다. 이것은 IQ와의 상관관계가 없다. 예측력을 높여주는 인자는 이것이 전부이다. 교육기간이 약간의 예측타당도를 높여줄 뿐이고, 얼마나 많은 과목을 들었는가는 아무런 관련이 없다. 이전 직장에서의 직무수행능력은 이미 직무를 수행하는 단계에 있는 사람에게는 관련이 있을지 몰라도, 시작하는 사람과는 관계가 없다. 이런 결과 중 몇 가지는 직관에 반하는 것이다. 왜냐하면 IQ가 다른 요인들과 중복되기 때문으로, 습득력이 빠른 사람은 이전 직장에서 좋은 수행능력을 보여줬을 것이지만, 이 자체가 이미 IQ와 높은 상관관계가 있기 때문에 예측타당도에는 도움이 되지 않는 것이다.

Further factors consistently found to add to prediction of performance are integrity and conscientiousness: these do not correlate with IQ23. No additional predictability comes from the number or nature of outside interests; years of education adds little to predictive validity; and the number of courses a person has been on is of no value (so much for how we measure ‘ continuing professional development’). Previous job performance adds to prediction for those already in the profession, but adds nothing at entry. Some of these results are counter-intuitive: this is because IQ overlaps with other things. So a quick learner will have good performance in a previous job which will correlate so highly with IQ that it adds little to predictive validity20.

탈락(academic failure)를 예측하는 요인은 무엇인가?

WHAT FACTORS PREDICT ACADEMIC FAILURE IN MEDICINE?

의학에서 예측인자에 대해 연구한다고 할 때 가장 먼저 집착(?)하는 것은 시험 결과이다. 지금까지 보았을 때 시험 통과의 예측인자를 연구한 논문이 가장 많을 것이다. 이는 중간에 탈락하는 의과대학생에게 들어가는 경제적, 개인적 비용을 고려했을 때 합당한 것이다. 보통 8%~10%정도가 이렇게 탈락한다고 보고되고 있다. 그러나 많은 연구에서 'failure'를 평가할 때 자퇴(exclude)하는 학생 뿐만 아니라 재시험을 보는 학생까지 포함하는 경우가 많고, 따라서 이러한 예측인자들을 주의해서 봐야 한다. 비록 학생들이 고등학교 때에는 0.4%에서 10%사이의 상위권 학생들이었지만, 이 성적과 의과대학 시험 성적에는 상관관계가 있다. 일부 영국 연구들은 일부 과학과목에서 A학점을 받은 것이 의과대학시험 성적을 예측한다고 보고하고 있다. 영국 외 지역에서도 유사한 결과가 있으나 이러한 것이 장기적으로 봤을 때는 성공 또는 실패에 차이를 주지 않는다.

The first thing that strikes anyone exploring the work on predictors in medicine is that we are obsessed with exam results: by far the largest number of papers examines predictors of passing exams. This may be justified because of the economic and personal waste of losing students who begin a medical degree but fail to complete, with loss from schools that select at entry, both in the UK and elsewhere, generally reported between 8% and 10%24, 25, 26, 27. However, most studies assess ‘failure’ in broad terms to include all students who re-take an examination, as well as those who are excluded from the course, so predictors should be treated with caution. Although virtually all students are high academic achievers at school, from the top 0.4%8 to the top 10%29, school and medical exam scores do correlate, with contribution to variability reported between 16%29 and 58%30. Some UK studies show that certain science A levels predict exam success, variously putting biology, chemistry or physics in prime place31, 32, 33, and research from outside the UK reports associations between performance in physical sciences and in medical exams34, 35, 36. Generally this association falls later in the course, with no difference to longer term success or failure37, 38, 39, 40.

비학업적 요인들도 성공 또는 실패를 예측하는 것들이 있는데, 일부 연구자들은 더 나이가 많은 학생일수록 시험에 탈락할 가능성이 높다고 하기도 하나, 다른 연구자들은 이러한 차이는 없다고 보고하고 있다. 몇몇 미국 연구들을 보면 여성 또는 소수인종 학생에서 탈락률이 더 높다고 보고하고 있으며, 한 학교에서는 affirmative action으로 입학한 학생들이 전통적 기준을 통해 들어온 학생들과 졸업하는데 있어서 차이가 없다고 보고하고 있다. 영어가 모국어가 아닌 나라에서는 영어를 얼마나 유창하게 하는가가 중요하며, 미국에서는 소수 인종에서 독해 능력이 학업 성취를 예측해주기도 했다. 비인지적 요인들은 백인 남성보다 여성과 소수 인종에서 더 강력한 예측인자였으며, 여성에 있어서 면접점수와 이전 관련 경험이 시험 점수보다 예측성이 더 높았다. 소수인종 학생에게 있어서는 locus of control과 자기평가 능력이 예측인자였다. 

Non-academic factors also predict exam success or failure. Some researchers report that older students are more likely to fail exams36, 38, 41, but others have not found this42. Several US studies found higher failure rates among women and ethnic minority students, although most eventually graduate36, 38, 41, and one school reported that students admitted through affirmative action were as likely to graduate as those admitted by use of traditional criteria43. Proficiency in English is important for students for whom English is not their first language44, 45, and in the US, reading skills of disadvantaged minority students have been shown to predict academic success46. Non-cognitive factors are stronger predictors for women and ethnic minority students than for white men in the US. For women, interview ratings and previous relevant experience were more predictive than previous exam scores47, while for ethnic minority students, locus of control and ability to self-evaluate were predictors48, 49. One US study showed that different cognitive and non-cognitive factors correlate with academic success in different schools, so different cultures and teaching styles influence outcome50.

미래에 다가올 어떤 failure는 피할 수 없는 것이고, 일부 학생들의 진로희망이 바뀌는 것을 막을 수는 없다. 그러나 두 의과대학에서 학생을 잘 선발하고 잘 지원을 해주면 긍정적 효과를 보여줄 수 있다는 결과가 있다.

It has been argued that we cannot reduce loss further51, because some failure is inevitable and we cannot avoid a few students' wanting to change career. However, two medical schools have shown that careful selection and good support can have a positive impact. 

뉴캐슬 연구 결과를 보면, 낮은 면접점수와 향후 탈락간에는 높은 상관관계가 있었지만, 낮은 학업점수와는 그러한 상관관계가 없었다.

In Newcastle, New South Wales, for five years 50% of students were selected on academic marks alone but underwent a lengthy structured interview which was not used for selection. As a result, some students were admitted with very low interview scores. The remaining 50% were selected from a wider band of academic performance but scored high in interview. Analysis after ten years showed a significant correlation between low interview score and later drop-out but no correlation between academic score at entry and drop-out. Reasons for dropping out were academic failure or a variety of personal reasons, including lack of motivation for study or for medicine28. 

McMaster에서는 remediation을 잘 해준 결과 100명의 학생 중 한 학생만이 학업적 이유로 exclude되었고, 3명은 진로를 바꾸었으며 8%는 remedial이 도움이 되었다.

Another example of low drop-out comes from McMaster University in Ontario, which also invests heavily in selection and in addition offers ‘remediation’ for students having academic difficulty. In one five-year period in a class of 100 students, only one student was excluded because of academic failure, 3 changed careers, while 8% had remedial help52.

우수한 임상 수행능력을 예측하는 것은 무엇인가?

WHAT PREDICTS GOOD CLINICAL PERFORMANCE?

• 임상수행능력은 입학전 학업성적만으로 예측되지 않는다. 
• 나이와 성별 모두 임상 수행능력을 예측하지 못하며, physical science를 과거에 공부했는지도 관계 없다.
• 그러나 이전 영어 학습과 인문학 학습이 임상 수행능력과 상관관계가 있음을 보여준 연구가 있고, 일부 보고서에서는 입학시 면접 점수와의 상관관계를 보여주기도 했다. (입학시 면접과는 상관관계가 없다는 연구도 있다.)
• 지원자에 대해서 매우 자세히 평가하는 학교에서는 공감과 동기부여가 특히 중요하다는 것을 보여주기도 했다.

Investigators looking for early predictors of what makes a good clinician generally use reports from clinical clerkships and from the house officer or intern year. However, we should note that drop-out will mean that some unsatisfactory students will have left before the house officer year. Clinical performance is not generally predicted by pre-entry academic scores1, 35, 53, 54, 55, 56, 57: the one report of correlation between matriculation scores and clinical performance noted that matriculation scores included 50% contribution from school teacher assessment58. Neither age nor gender predicts clinical performance, nor does previous study of physical sciences, but there is evidence that previous study of English and humanities correlates with better clinical performance5, 34, 59. There are some reports of association between clinical performance and admission interviews55, 56, 60, 61, although others reveal no correlation54, 58. In a school that carefully evaluates applicants, empathy and motivation to be a doctor were found particularly important in predicting both clinical and academic success62.

미래 수행능력의 예측인자를 평가하기 위한 가장 타당도 높은 방법은 무엇인가?

WHAT ARE THE MOST RELIABLE PROCEDURES TO ASSESS PREDICTORS OF FUTURE PERFORMANCE?

지금까지 우리가 가지고 있는 최선의 도구는 구조화된 면접이다.

If we can agree that there are certain characteristics that we want to select in prospective doctors, what is the best way of doing this? Research shows that, if we want to add usefully to a measure of intellectual ability in predicting later job performance, our best instrument is the structured interview. 

While an unstructured interview adds about 8% to prediction of subsequent performance, the structured interview adds around 24%63. 

심리검사로 개인적 특성을 알아내는 것이 미래 수행능력 예측에 도움이 될 수 있지만, 만약 선발 도구로 사용하고자 한다면 '정답'을 찾아내기 어렵지 않으므로 이러한 타당도가 손상될 가능성이 있다.

Psychometric tests to measure desirable personal characteristics do predict future performance, but their validity may be compromised if they are used as a selection tool: 

the desired answer is not usually difficult to identify, and applicants who lack integrity are the most likely to manipulate the results64. 

However, some schools have applied psychometric tests at the point of entry rather than using them to select, and have found correlation between these tests and scores given in interview65, 66. This suggests that a well conducted interview may give similar information and that, if constructed to assess desired characteristics such as conscientiousness or helpfulness, it will give a reasonably reliable evaluation20.

이 전에 이 사람을 가르쳤거나 고용했던 사람의 reference가 도움이 될 수 있다. 그러나 법에 따라 employee에 의해서 고소를 당할 가능성이 있고, 평가자의 '동기'가 무엇인지 알 길이 없다.

Character references from a previous employer or tutor have potential to add to prediction. However, legislative changes in the US in the 1980s meant that an employer giving an adverse report could be sued by the employee: as a result, the predictive validity of personal references in the US has fallen to almost zero20. 

The reliability of UCAS references in the UK may be similarly threatened. The motivation of the referee is uncertain: some tutors may feel their first loyalty to their student, others may feel compromised by recent data protection legislation that removes the confidentiality of previous years. 

One medical school in New Zealand has adapted the traditional reference system by writing to head teachers with specific questions, and requesting a rating of the candidate's qualities against the level the head teacher believes to be desirable in a doctor. The long-term predictive validity of this method has not been published, but the school believes it provides valid information and correlates well with other non-cognitive indices (and not at all with academic scores)35. 

일부 학교에서는 small group에서의 수행능력을 통해 실시간으로 대인관계능력을 평가하기도 한다.

Some schools, particularly those which do a lot of small-group work in the course, use an assessment of performance in small groups as a ‘live’ way to assess interpersonal skills29, 52. Evaluation of students in this setting correlates highly with interview scores, and is reported to predict both problem-solving ability and group interaction52.

현재의 '최선의 진료'를 구성하는 것은 무엇인가?

WHAT CONSTITUTES CURRENT BEST PRACTICE?

In summary, the evidence is that we need to select students with good intellectual ability and that examinations, despite limitations, have some validity. For some candidates—e.g. older applicants, or those from disadvantaged social backgrounds—we may want to look for reliable measures of intellectual ability other than the traditional A levels. We seek individuals who are conscientious and have integrity, who are empathic and motivated to become doctors, and who are psychologically robust enough to enjoy a successful medical career. Some medical schools, mainly outside the UK, have already recognized best practice and have put great care and resource into their selection procedures, with well-planned structured interviews, focused reports from schools and evaluation of interpersonal behaviour. As detailed above, there is evidence that this investment is worthwhile in terms of the suitability of students selected, and economically in terms of student loss during the course.

우리는 지금 어디 있는가?

AND WHERE ARE WE IN THE UK?

The greatest single barrier to a more careful selection process in the UK is the amount of resource that each school has to invest. At present, would-be medical students apply to up to four medical schools. All but four of the UK's present twenty-four medical schools interview about 500 to 1000 applicants for their five or six year MB BS courses. Many interviews are still unstructured, and not all schools require their interviewers to be trained. It is unusual for the interview to be more than 15 or 20 minutes, and while brief interviews may be reliable67 the validity of a 15-minute interview is doubtful68. The fact that many candidates are interviewed four times underlines the wastefulness of our present national procedure, but the cost to individual schools to improve radically would be prohibitive. Our present system does not offer society the best practice available: at present we almost certainly turn away people who would make good doctors and accept some who will be mediocre or poor. We could probably reduce loss from the medical course, and so save money and save personal distress among those who were allowed to make an unwise choice. We could also be more just to applicants, and begin the process of education by showing that we are very serious about the kind of personal qualities that we want in a doctor.

The Civil Service, the Armed Forces, and many business corporations have had selection boards for many years: the Civil Service believe these to be money well spent, and industry has gone further and demonstrated their cost effectiveness20. Those medical schools which invest heavily in their selection procedures admit that it is not cheap: on the other hand, it is not cheap to lose students unnecessarily or to employ a poorly motivated or unhappy doctor. There is a strong argument for pooling resources so that applicants get one good assessment instead of four poor ones. This does not preclude medical schools' maintaining individuality and some degree of choice, and candidates will continue to visit schools and attend open days. However, it is time that UK medical schools got together to collaborate in setting up a first-class selection process that is fair to society and fair to all those people who hope to be the doctors of tomorrow.

Hughes, P. (2002). Can we improve on how we select medical students?. Journal of the Royal Society of Medicine, 95(1), 18-22.

The Acceptability of the Multiple Mini Interview for Resident Selection

Marianna Hofmeister, PhD; Jocelyn Lockyer, PhD; Rod Crutcher, MD

캐나다 Alberta의 Alberta’s International Medical Graduate Program (AIMGP)에 지원한 학생을 대상으로 실시한 MMI에 대한 연구로서, 가정의학과 레지던트에 지원한 해외의과대학졸업생(IMG)의 면접에 대한 연구이다. 

Background and Objectives: This study describes and assesses the acceptability of the multiple mini interview (MMI) to both international medical graduate (IMG) applicants to family medicine residency training in Alberta, Canada, and also interviewers for Alberta’s International Medical Graduate Program (AIMGP), an Alberta Health and Wellness government initiative designed to help integrate IMGs into Canadian residency training. IMGs are physicians who completed undergraduate medical education outside of Canada and the United States. IMGs who live in the Canadian province of Alberta may obtain a limited number of government-funded positions for residency training by applying to AIMGP. 

12개 스테이션으로 이루어진 MMI를 설꼐하였고, 프로페셔널리즘에 대한 비인지적 특성을 보고자 했다. 가정의학과 교수와 의학교육자들이 문항을 개발하였으며, 시험이 종료된 후 설문을 하였다.

Methods: A literature review and faculty and medical community consultation informed the development of a 12-station MMI designed to identify non-cognitive characteristics associated with professionalism potential. Clinical scenarios were developed by family physicians and medical educators. Applicant and interviewer posttest acceptability was assessed using surveys. Quantitative data were analyzed using descriptive statistics, and qualitative data were analyzed using content analysis and thematic description. 

면접관들의 만족도가 높았으며, 캐나다 가정의학의 맥락에 잘 맞는 문항이라고 평가하였다. 지원자와 평가자 모두 8분이 충분한 시간이라고 했고, 지원자들은 이 면접이 성별 또는 문화 BIAS에 영향을 받지 않는다고 느꼈다고 응답했다. 평가자들은 MMI가 공정한 평가법이라는 것에 동의하였다.

Results: Our research demonstrates evidence for applicant and interviewer acceptability of the MMI. Interviewers reported high levels of satisfaction with the time-restricted process that addressed multiple situations pertinent to the Canadian family medicine context. Applicants and interviewers were each satisfied that 8 minutes was enough time at each station. Applicants reported that they felt the process was free from gender and cultural bias. Interviewers agreed that this MMI was a fair assessment of potential for family medicine. 

Conclusions: Standardized residency selection interviews can be adapted to measure professionalism potential characteristics important to family medicine in ways that are acceptable to IMG applicants and interviewers.

Background

MMI

MMI개발의 역사, Validity, Generalizability의 근거 확보. Acceptability 확보

The MMI is a multi-station interview with one interviewer rating candidates’ performance at each station. The MMI was developed at the Michael G. DeGroot School of Medicine at McMaster University in Hamilton, Ontario, Canada, and has been validated there,5,14,15 at the University of Calgary,6,16 in Australia,17 and in the UK.18 This interview instrument has demonstrated evidence for generalizability and validity in relation to future clinical and licensing examination performance as compared to traditional interview methods.5,7.9 Further, the MMI has established acceptability with members of applicant and interviewer stakeholder groups at the admissions level.5,16,17

MMI는 프로페셔널리즘 역량을 평가할 수 있는 flexibility가 있으며, 우리는 CFPC가 정의한 네 원칙에 따라 문항을 개발했다.

The flexibility of the MMI allows programs to select applicants whose behaviors best align with professionalism competency expectations. In this assessment, we developed an assessment in accordance with the College of Family Physicians of Canada’s four principles.6,19,20 The four family medicine principles are: 

• the family physician is a skilled clinician, 
• family medicine is a community-based discipline, 
• the family physician is a resource for a defined practice population, and 
• the patient-physician relationship is central to the role.20 

These principles provide a framework with which competencies, such as those outlined by the Accreditation Council for Graduate Medical Education (ACGME) (ie, professionalism, interpersonal and communication skills, and systems-based practice), can be addressed.

프로페셔널리즘 : 정의, Developmental, Context specific

“Professionalism potential” is derived from medical professionalism theory.21 The attributes associated with medical professionalism and professional behavior are of universal concern.22 Medical professionalism is conceptualized as developmental.5, 6 Professional behavior is context specific or situation dependent.23 This means that evidence of aspects of professional behavior in one challenging situation does not predict different aspects of professional behavior in another. It follows that professionalism potential for family medicine may be examined in multiple situations critical to best family practice using this new interview methodology.

연구의 목표

Objectives

The acceptability of the MMI in IMG groups and the acceptability of the MMI for professionalism potential measurement in IMG individuals for family medicine residency selection have not been previously investigated. The objective of this research was to investigate the acceptability to family medicine interviewers and to IMG applicants themselves of an MMI designed to measure professionalism potential of IMG applicants.

Methods

The process of preparing for the MMI and constructing stations began in March 2006 with the formation of the AIMG MMI Committee. The committee included a family physician chair who oversaw the process and made final decisions relating to what characteristics would be examined in which scenarios. Ethics approval for the study was provided by the University of Calgary Conjoint Health Research Ethics Board.

MMI Development

Station construction was guided by a table of specifications based on previously examined characteristics, characteristics important to family medicine,24 and those associated with medical professionalism.21 The characteristics examined in previous interviews included ...

relationship-building skills, 

team skills, 

recognition of professional limitations, 

integrity, 

decision-making skills, 

problem-solving skills, and 

communication in caring relationships. 

The medical education literature pertaining to professionalism and desirable personal traits in medical practitioners was reviewed.24-26 A comprehensive list of characteristics that might be assessed using the MMI was constructed and circulated to decision makers. A structured formal inquiry through e-mail correspondence, meetings, and discussion was used to gather input from the family medicine residency program directors at the University of Calgary and the University of Alberta and from other community-based and academic family physicians. This information was used to construct content-specific situations that would enable each characteristic to be assessed. The AIMG MMI Committee ultimately developed station content, question probes, and background information.

MMI Development

Ten stations, each designed to measure one characteristic, presented situations the applicant might face in a family medicine residency.27 The characteristics tested were ...

• teamwork, 
• honesty, 
• ability to accept feedback about one’s self, 
• ability to accept self-limitations, 
• caring and compassion, 
• responsibility taking, 
• time management, 
• the ability to accept professional limitations, 
• cultural sensitivity, 
• motivation for family medicine, and 
• goal setting. 

A sample station is shown in Table 1.

IMG Applicants

To qualify for the MMI, applicants were required to have completed the AIMGP’s entry requirements. These criteria include...

a passing score on the Medical Council of Canada Equivalency Examination, 

a passing score on the Medical Council of Canada Qualifying Examination Part 1, and 

proof of successful completion of undergraduate medical education in a medical school listed in the Foundation for Advancement of International Medical Education and Research (FAIMER) directory. 

In addition, applicants were required to pass all components of the AIMGP objective structured clinical examination (OSCE). 

Specifically they had to pass the minimum number of stations for the clinical skills component and exceed the benchmark scores on the communication, oral, and written English proficiency tests. 

Alberta International Medical Graduate applicants for family medicine residency training positions who exceeded the minimal pass level on the clinical skills OSCE were e-mailed an invitation to the family medicine MMI following notification of their success on the OSCE. After each MMI session, applicants were asked to complete the acceptability survey.

Interviewers

• 가정의학과 교수와 고년차 레지던트들이 면접관으로 들어감
• 면접관은 2주 전에 2시간의 의무적 트레이닝 세션에 참가해야 함
• 면접 48시간 전에 스테이션에 대한 정보 제공
• 모든 면접은 캘거리대학에서 진행됨.
• 면접관 특성에 따라 면접 점수가 달라질 수 있다는 연구 결과에 기반하여 면접관의 구성은 professional status와 gender에 따라서 하였음.

Interviewers were family medicine faculty and senior family medicine residents at the University of Alberta and the University of Calgary, community physicians from both urban centers, and stakeholders from other medical community-related groups (ie, medical education, language education, and human resources). All of the interviewers participated in a mandatory 2-hour training session 2 weeks before the MMI. Interviewers then received their station information 48 hours before the interviews took place. All of the interviews took place at the University of Calgary. Because previous research has shown that applicant scores may be related to interviewer characteristics, interviewers were organized in tracks and stations according to their professional status and gender to minimize these effects on applicant scores.14,28

Interview Procedure

• 한 스테이션당 1명의 면접관
• 두 세트를 활용하였고, 세 세션으로 나눠서 진행하였음.
• 2분간 문 앞에서 정보를 숙지하고 8분간 면접 진행

The MMI uses a multi-station format that is similar to an OSCE. Each applicant moves through the same set of stations and is evaluated by a single interviewer at each station. More than one set of stations can be run at the same time. We used two sets of stations per session and ran three sessions in a single day. At each station, the applicant read the information posted on the door for 2 minutes and discussed his/her response with the interviewer for 8 minutes. After each session, applicants were invited to complete the applicant survey and at the end of interview day, interviewers were invited to complete the interviewer acceptability survey.

The acceptability of the multiple mini interview for resident selection.

Standardized residency selection interviews can be adapted to measure professionalism potential characteristics important to family medicine in ways that are acceptable to IMG applicants and interviewers.

An overview of the world’s medical schools

JOHN BOULET1, CAROLE BEDE2, DANETTE MCKINLEY1 & JOHN NORCINI1

1FAIMER, Philadelphia, USA, 2ECFMG, Credentials, Philadelphia, USA

배경

Background

글로벌 보건의료인력 차원에서 적절한 훈련을 제공하는 것은 매우 중요하나, 최근의 환경을 보면 보건의료시스템에 대한 수요가 많아지고, 의사들은 지역과 지역을, 국가와 국간을 자유롭게 오갈 수 있다. 즉, 의학 수련에 대한 선택 옵션이 많아졌는데, 그 결과로 수련 기관의 분포와 질에 대한 정보를 수집하는 것이 보건의료인력에 대한 계획 수립 차원에서 매우 중요한 일이 되었다. 의학교육은 확실히 진로 선택 패턴 및 진료 패턴에 영향을 주고 있고, 그 결과로 전 인구적 건강에도 영향을 미치는데 이는 특히 덜 개발된 지역에서 심각하다.

Providing training that will ensure an adequate global healthcare workforce is essential. However, in today's global environment, where there are increasing demands on healthcare systems, physicians are free to move from locale to locale or even from country to country. More important, for many of these individuals, there have been, and continue to be, numerous options as to where the medical training can take place, including institutions located outside their home countries. As a result, obtaining information on the distribution and quality of training institutions is critical to health workforce planning (World Health Organization 2006). Medical education will certainly affect practice patterns and influence career choices, thereby having some distributed net effect on population health, especially in underdeveloped regions or those countries where relatively few practitioners are being trained. Having information about medical schools, including where they are located, and how this has changed over time, is paramount.

일부 의학교육의 global pipeline을 다룬 연구들이 있지만, 의과대학의 수가 빠르게 증가하면서 '현재의' '정확한' 정보를 수집하는 일이 더욱 중요해졌다. 의사 교육에 대한 global capacity를 제대로 이해하려면 데이터 수집이 향상되어야 하고, 또한 무엇보다 중요한 것은 그 정보가 공유되어야 한다.

Although some research has been conducted to track the global pipeline of medical education, the rapid growth in the number of medical schools demands that any information collected is both current and accurate. In 2002, Eckhert described the distribution and physician output of the world's medical schools (Eckhert 2002). She concluded that in areas of predicted substantial population growth, the production of physicians is not sufficient to overcome low physician–population ratios. Moreover, due to incomplete data, tracking the number and distribution of medical schools and their student capacity was found to be an arduous and complex task. Therefore, to better understand the global capacity to educate physicians, the available data sources need to be improved and, most important, shared.

의과대학에 대한 이러한 정보원은 몇 가지가 있고 어떤 것은 다른 것보다 더 정확하거나, 더 현재의 상태를 잘 반영하는 것도 있다. 그러나 현재 이러한 자료들은 모두 한계점이 많다.

There are a number of sources of information concerning medical schools, some more accurate and current than others. 

• Historically, the World Health Organization (WHO) published and maintained the World Directory of Medical Schools (World Health Organization 2000). This comprehensive directory, last published in 2000, provides descriptions of medical education programs and lists of training institutions, by country or area. Although the WHO website has additional data for some schools up to the 2004 calendar year (World Health Organization 2004), much of the information presented reflects the academic situation several years prior to that. 

• The Institute for International Medical Education (IIME) maintains a database of medical schools, including links to most of the medical school home web pages. As of December 2005, there were 1848 schools listed in 166 countries (Institute for International Medical Education 2005). Much of the information in the database was generated from a medical school survey conducted in 2000. Although this survey solicits contact information, admission requirements, enrollment data, assessment methodology and curriculum content, relatively few medical schools appear to have provided these detailed data. Moreover, this information is not currently available on the public domain website. Similar to the WHO Directory, a listing in the IIME database does not serve as a grant of international recognition of the medical school.

• The Association of American Medical Colleges (AAMC) maintains a listing of all US and Canadian Medical Schools, including links to each school's website. In addition to this listing, the AAMC provides a Curriculum Directory that contains detailed information on courses offered, clerkships, promotion and graduation requirements, etc., by medical school (Association of American Medical Colleges 2005a; Association of American Medical Colleges 2005b). 

• Similar to the AAMC, the American Association of Colleges of Osteopathic Medicine (AACOM) provides comparative medical school information for all osteopathic medical colleges in the US. 

• For medical schools worldwide, the International Federation of Medical Students’ Associations (IFMSA) created a curriculum database that includes country-based data on medical schools, including medical training period, number of graduates, residency requirements, and the existence of a national accreditation process (International Federation of Medical Students' Associations 2005). 

• To date, however, relatively few countries are listed. Similar to the US and Canada, for some countries (e.g. India), the responsible recognizing or accrediting bodies provide detailed information on the management and characteristics of the medical colleges under their jurisdictions (Medical Council of India 2005). 

• Various other organizations, both public and private, also provide partial listings of the world's medical schools and, in some instances, more comprehensive data on the qualities of the training programs. Unfortunately, much of this more relevant and detailed information is only available on individual medical school websites.

FAIMER는 IMED를 보유하고 있다. IMED는 '최신의' '정확한' '지속적으로 업테이트되는' 데이터베이스라 할 수 있다.

The Foundation for Advancement of International Medical Education and Research (FAIMER) maintains the International Medical Education Directory (IMED) (Foundation for Advancement of International Medical Education and Research 2005). 

IMED is a free, web-based resource of the world's medical schools. 

The directory provides an accurate and up-to-date resource containing information on medical schools that are recognized by the appropriate government agencies in the countries where the schools are located.1 

Unlike the inclusion criteria employed by some of the other organizations who maintain medical school resources, with the notable exception of the WHO,2 a medical school is only listed in IMED after FAIMER receives confirmation from the Ministry of Health or other appropriate agency that the school is recognized. 

In addition, medical students who wish to pursue graduate medical education in the US must have their medical school listed in IMED. This is one of several requirements that are necessary for certification by the Educational Commission for Foreign Medical Graduates (ECFMG®). As a result, IMED must remain current, and is continuously updated.

Although there may be numerous schools that are not recognized within their host country, thus precluding their listing in IMED, the International Medical Education Directory does provide a starting point for describing the world's medical schools and colleges. The information available in IMED includes the school's current name and university affiliation, previous names and contact information. In addition, basic demographic information is readily accessible.

결과

Results

235개 국가 중에서 169개 국가는 하나 이상의 의과대학을 보유하고 있으며, Top20국가가 Table 1에 있다. 2006년의 IMED목록에 따르면 인도가 가장 의과대학이 많고, 그 다음으로 미국이 따르고 있다. 전 세계 의과대학의 1/3이 다섯 개 국가에 있으며, 절반의 의과대학은 10개 국가에 있다.

Of the 235 countries and dependencies in the world, 169 have at least one medical school. The countries with the most medical schools are presented in Table 1. Based on IMED listings in April 2006, India has the most recognized medical schools (n = 219), followed by the United States (n = 147, allopathic and osteopathic). Over one-third of all the world's medical schools are located in one of five countries; nearly half are located in 10 nations.

지역별 의과대학 분포는 Table2에 정리되어 있다. 평균적으로 330만명당 한 개의 의과대학이 있다.

The number of medical schools by continent and region is presented in Table 2. The 2004 continent and region populations, medical school densities, number of physicians and physician densities are also provided. While there are some associations amongst the number of medical schools, the population and the number of physicians, there is substantial variation from region to region. Based on the IMED total of 1935 operating medical schools, there is, on average, one medical school for every 3.3 million persons in the world. 

아시아에는 가장 많은 인구와 가장 많은 의과대학이 있지만 60%의 인구가 있는 것에 반해 44%의 의과대학만이 있다. 의사 밀도도 낮다. 

Asia, with the largest population (approximately 3.9 billion people) has the most medical schools (n = 860). However, while over 60% of the world's population resides in Asia, only 44% of the medical schools are located there. Moreover, physician density is low, with less than one physician, on average, per 1000 population. 

16%의 의과대학이 북미에 있으나 8%의 인구만이 북미에 산다. 

In contrast, nearly 16% of the world's medical schools are located in North America; only 8% of the world's population resides there. The relatively large number of practicing physicians, especially in the North region (includes the United States, Canada, Bermuda, Greenland, and Saint Pierre and Miquelon), results in a continent-based density of 2.2 physicians per 1000 inhabitants.

남아메리카에는 218의 의과대학이 있다.

There are currently 218 medical schools operating in South America. With a 2004 population of 366 million, this represents one medical school for every 1.7 million inhabitants. 

아프리카에는 127개의 의과대학이 있으며 8억7천3백만명이 살아서 690만명당 1개의 의과대학이 있다.

In Africa, where there are only 127 listed medical schools and a population of 873 million, there is one medical school for every 6.9 million inhabitants, and only 231,426 total physicians. As a result, physician density is particularly low, with about one doctor, on average, for every 4000 people. In Western, Eastern and Middle Africa, where there are relatively few medical schools for the given population, physician density is also extremely low, averaging about 0.12 per 1000.

의과대학 밀도와 의사 밀도 사이에는 강한 상관관계가 있다. 유럽과 아프리카는 그 극과 극을 보여준다.

In general, there is a reasonably strong relationship, at least at the continent and regional levels, between medical school density and physician density (Pearson correlation (region) = 0.64). Europe, with approximately one medical school for every 1.9 million inhabitants, has a physician density of 3.4/1000. At the other extreme, Africa, with one medical school for every 6.9 million inhabitants, has a physician density of 0.26/1000. 

그러나 지역 수준에서 이러한 상관관계는 대륙 수준의 상관관계만큼 높지는 않다.

At the regional level, however, some of the relationships are not as strong. Eastern Europe, with 127 medical schools and a population of approximately 300 million, has one medical school for every 2.4 million inhabitants, a comparatively small ratio when contrasted with other European regions. However, with over one million doctors, physician density is relatively high at 3.6/1000. In contrast, the Caribbean has the most medical schools per unit population (1.4/million) but a physician density (2.3/1000) that is comparable to that of the North region of North America (0.5 medical schools/million population; physician density = 2.5/1000).

인구가 4백만 이상인데 의과대학이 없는 국가는 거의 없다. 있긴 있다.

There were relatively few countries with populations of greater than four million that had no medical schools. 

These included Eritrea and Somalia, both in Africa. In total, of the 57 African nations, 16 did not have a single medical school. 

반대로 인구는 작지만 둘 이상의 의과대학을 보유한 국가도 있다.

In contrast, there are several countries with small populations that have one or more medical schools. 

Countries with operating medical schools and populations of less than two million are presented in Table 3. The Netherlands Antilles, with a resident population of approximately 218,000, has six operating medical schools, yielding an average of one medical school per 36,000 individuals. Similarly, Belize, with a relatively small population of 270,000, has six medical schools. Montserrat, with a resident population of fewer than 10,000, has two medical schools.

Although some general information is available in IMED for institutions in the US and Canada, the database is focused primarily on international medical schools. 

언어 : Of the 1771 medical schools located outside the US or Canada, 664 (37.5%) offer instruction in English. However, only 22% of the countries where these schools are located list English as an official language. Within the group of schools where English is not a language of instruction, the most common teaching languages were Spanish (21%), Chinese (12%), French (8%), Portuguese (8%), Japanese (7%) and Russian (6%). 

교육과정 : The minimum curriculum duration is four years; the maximum is eight years. Based on the cohort of international medical schools, 1620 (91%) have information listed as to when the medical program started. 

설립시기 : A total of 202 medical schools started in the nineteenth century or earlier. Between 1900 and 1949, 235 medical schools began training students. Between 1950 and 1999, 1062 medical schools were created. This influx represents approximately two-thirds of all currently operating international medical schools. 

The largest relative growth (1950–99) was experienced in South America, where 153 (of 193 schools with a verified start date) began operations. In Brazil, 66 (83% of the schools with a verified start date) began operating between 1950 and 1999. 

A similar expansion (1950–99) occurred in Asia, where 577 (73%) of the 794 Asian medical schools with a verified start date began operating. In China, 104 schools (82%) were created between 1950 and 1999. 

Most recently (2000–present), some of the largest relative growth occurred in Oceania: seven schools began training physicians, representing 32% of 22 listed medical schools for this continent. 

IMED : In Asia, 76 medical schools were added to IMED in 2000 or later. Most of this growth could be attributed to India, where 46 schools either started operations or achieved recognition. In terms of recent overall counts, China also had a large country-based growth in medical schools: 14 schools were recognized and added to IMED between 2000 and 2006. From a regional perspective, the Caribbean has also seen a large recent growth in the number of medical schools. Between 2000 and the present, 13 medical schools were added to IMED, including, amongst others, five in Belize, three in Saint Lucia and two in Aruba.

고찰

Discussion

Based on IMED listings, there is a fairly wide dispersion of medical schools throughout the world. Interestingly, nearly half of all the medical schools are located in 10 countries. While some of these 10 countries have relatively large populations (e.g. China, India), and would logically have numerous educational institutions, some do not (e.g. Iran). From a physician production perspective, this would suggest that, at least for some counties or regions, the distribution of medical schools may not be keyed to local needs. Even if medical school training programs were developed to satisfy national or regional requirements, migration may have a significant impact on local physician density. 

For example, although there are 219 operating medical schools in India, physician density within the south-central Asian region is only 0.65/1000, about half of that for the entire world. 

While part of this can be explained by the relatively large population, almost 60,000 Indian physicians practice in the US, United Kingdom, Canada and Australia (Mullan 2006). These Indian-trained doctors are the largest émigré physician workforce in the world. 

의사 양성과 국가 수요간의 관계를 그리는 것은 복잡하고 다면적이다.

Mapping the relationship between physician production and national requirements is, however, complex and multidimensional. 

First, the population (or population health)–medical school relationship is certainly dependent on medical school class size, curriculum focus (e.g. public health), and clinical experiences of the graduates. While the variability in class sizes would tend to average out over large regions, this is unlikely to be the case at the country level, especially for nations with relatively few medical schools. 

Second, for some schools, physician training, to some extent, is certainly not directed primarily towards addressing local supply. Nevertheless, provided that these physicians go to areas of need, the physical location of the medical school may not be that important. 

Finally, although physicians are extremely important in any healthcare delivery model, the role of other practitioners (e.g. nurses) and advanced technology will certainly have some impact on resource needs.

의과대학과 의사의 분포가 균등하지 못한 것은 자명해보인다.

The more detailed analysis, by continent and region, of medical schools by population and physician density clearly shows that medical schools and physician resources are not dispersed uniformly. 

6%의 인구에 14%의 의과대학이 있는 남아메리카의 경우, 캐리비안의 의과대학 비율은 확실히 높은 편이다.

For example, over 11% of the world's medical schools are located in South America yet less than 6% of the world's population resides there. In contrast, nearly 14% of the world's population resides in Africa, an area serviced by only 127 medical schools. From a regional perspective, the Caribbean clearly has a disproportionate number of medical schools. Historically, of the 25 Caribbean nations, 24 had an operating medical school at one time or another. Currently, there are 54 operating Caribbean medical schools, located in 16 different countries. The concentration of schools in this region is not surprising given the large number of American citizens who travel there for their medical education (McAvinue et al. 2005). In addition, physician density in this region is comparable to that for North America, suggesting that the medical education programs do, at some level, provide for local needs. 

However, more important than the excess of ‘offshore’ schools, there are some populated countries (e.g. Somalia), including 15 other nations in Africa, with no medical schools. While the physician workforce needs of these nations could potentially be met by other countries, there is no guarantee that other nations, especially those in Africa, could afford to lose their local doctors. Although efforts to redistribute, or create new, medical schools may alleviate some of the local supply problems, at least temporarily, a more pressing concern is physician migration (Cooper 2005; Hagopian et al. 2004). In essence, while the location of the medical school is fixed, the practice locations of medical school graduates are not.

의사들의 이주가 크게 영향을 주는 요인이긴 하나, 의과대학 밀도와 의사 밀도가 관계가 있다는 것은 적어도 지역 차원에서는 확실해보인다.

While physician migration certainly plays a role in the worldwide distribution of physicians, there remains a strong relationship, at least regionally, between medical school density and physician density. 

유럽의 예를 들면 인구에 비해서 의과대학이 많으며 의사 밀도도 높다. 의과대학 수를 늘리는 것이 해당 지역의 의사 밀도를 높이는데 기여할 것이다.

In Europe, for example, there are a large number of medical schools (n = 394) for the population, and a sizeable physician density of 3.4/1000. Although the medical school–physician density relationship is complex and time-lagged, dependent on migration patterns and questionably causal in nature, it would still suggest that increasing the number of medical schools in low-density areas should lead to overall increases in physician density. 

일부 국가에서, 즉 인구는 많은데 의과대학이 적은 국가에서는 국가 내에서 의사를 양성함으로서 의사 밀도를 높일 뿐만 아니라 국외 의사에 대한 의존을 낮추고 해외로 수련을 나간 의사들이 가질 수 있는 불확실성을 낮춰서 지역 인구의 건강에 기여할 수 있을 것이다.

For some countries, especially those with large populations and relatively few, if any, medical schools, training some physicians within the country, especially if migration can subsequently be curtailed, will serve to increase physician density. This will also curb dependency on expatriate doctors, quell uncertainties about the return of nationals sent abroad for training, and build a workforce that can provide proper healthcare for the local population (Broadhead & Muula 2002; Muula 2006).

The analysis of IMED data points to rapid growth, internationally, in the number of medical schools in the second half of the twentieth century. This surge in the number of medical schools probably corresponds to global economic and population growth, especially in developing countries such as India and Brazil. Whether or not this trend will continue is unknown. Based on IMED data collected since 2000, China (>10%), India (>25%), and the Caribbean (>40%) have seen substantial increases in the number of IMED listed medical schools. As the demand for healthcare service increases, other counties/regions are bound to expand enrollment at existing institutions and/or build new schools (AAMC 2006). For the purpose of global workforce planning, tracking this growth, and determining the relationship between physician training and local healthcare needs, is extremely important.

An overview of the world's medical schools.

The FAIMER Institute: creating international networks of medical educators

JOHN NORCINI, WILLIAM BURDICK & PAGE MORAHAN

Foundation for Advancement of International Medical Education and Research, Philadelphia, USA

(http://dohwan.tistory.com/443 와 거의 유사)

Description of the FAIMER Institute

Eligibility and application

Selection process

Curriculum

Session one

Intersession

Session two

Faculty

Educational resources

Formal evaluation of the FAIMER Institute

Plans for the future

The FAIMER Institute: creating international networks of medical educators.

Human resources for health in southeast Asia: shortages, distributional challenges, and international trade in health services

Churnrurtai Kanchanachitra, Magnus Lindelow, Timothy Johnston, Piya Hanvoravongchai, Fely Marilyn Lorenzo, Nguyen Lan Huong, Siswanto Agus Wilopo, Jennifer Frances dela Rosa

Trade in health services

An overview of trade in health services in southeast Asia

- 의료서비스의 Trade는 여러 동남아 국가에서 심각하며, 환자와 의료인력의 이동 둘 다를 포함하는 것임.

- 싱가폴, 말레이시아, 태국은 외국에서 환자를 끌어모으는 중요한 허브이며, 인도네시아와 필리핀은 의사와 간호사를 수출하는 허브이다.

- 캄보디아나 라오스와 같은 저소득 국가에서 의료인력의 이동은 언어 장벽이나 의사의 수준(qualification)을 밖에서 인정해주지 않는 문제 때문에 제한적이다. 그러나 이 지역의 다른 중소득 국가와 마찬가지로 환자가 외국으로 나가는 경우는 많다.

- 이렇게 해외로 의료서비스를 받기 위해 나가는 인구들은 대부분이 잘 사는 사람들로서, 그 지역에서 받기 힘든 의료서비스나 더 양질의 의료서비스를 받기 위해서 외국으로 가는 것이지만, 해외로 나가는 환자들 중 저소득층 인구도 많이 있다.

Trade in health services is substantial in many southeast Asian countries, and includes international movement of both patients and health workers.31 Singapore, Malaysia, and Thailand are important medical hubs, attracting patients from within and outside the region, whereas Indonesia and the Philippines export many doctors and nurses. In low-income countries such as Cambodia and Laos, movement of health workers is limited by language barriers and qualifications that are not recognised outside the respective countries; however, similarly to many of the middle-income countries in the region, there is a substantial flow of patients to facilities abroad. Although this flow consists mainly of better-off individuals who travel abroad for services that are either unavailable locally or are perceived to be of better quality, many patients from low-income segments of the population cross the borders from Laos, Cambodia, and Myanmar to access services in Thailand and Vietnam, or to use services as registered or unregistered migrants.

아래의 표는 다양한 형태의 의료서비스교환(trade in health service)를 보여주고 있다.

Table 3 shows countries' engagement in different modes of trade in health services.25 and 32 These modes are: 

(1) cross-border trade (telemedicine and medical transcription); 

(2) consumption abroad (movement of foreign patients); 

(3) commercial presence (foreign direct investment); and 

(4) temporary movement of natural persons (migration of human resources for health). 

이 보고서에서는 환자의 이동, 그리고 의료인력의 이동에 초점을 맞춰서 보고자 한다.

In this report we focus on the two modes of trade in health services in which countries in the region are actively engaged—movement of patients (mode 2) and movement of health workers (mode 4). Engagement of the southeast Asian region in mode 1 (cross-border supply) and mode 3 (foreign direct investment) remains limited. One example of mode 1 trade is the export of medical transcription services from the Philippines to the USA. In terms of foreign direct investment in the region, only 1% of total hospital beds in Indonesia are foreign owned, and 3% of total investment in private hospitals in Thailand is by foreign agencies.32

의사 인력과 간호사 인력의 유출

Export of doctors and nurses

필리핀과 인도네시아의 많은 의료인력이 동남아 다른 국가 또는 세계 여러 국가로 이동해간다. 말레이시아 역시 싱가폴, 중동, OECD국가로의 의료인력의 유출을 겪고 있으나, 말레이시아와 싱가폴은 동남아시아의 주요 유입국이기도 하다.

Many health workers from the Philippines and Indonesia migrate to countries within southeast Asia and to the rest of the world. Malaysia also experiences outmigration of health workers to Singapore, the Middle East, and OECD countries. However, Malaysia and Singapore are also popular destinations for health workers in southeast Asia.

2000년 기준으로 110,774명의 필리핀 간호사가 OECD국가에서 근무하고 있는 것으로 확인되며, 전체적으로는 163,756명의 필리핀 간호사가 해외에서 근무하고 있다. 매년 나가는 필리핀 간호사는 2000년대에 약 7600명이었으나 2009년에는 13000명으로 증가하였다. 사우디, 미국, 영국, 아랍에미레이트 등이 주요 이민 국가이다. 이러한 이주의 원인에는 임금 격차가 주로 작동한다.

About 110 774 Filipino nurses were estimated to work in OECD countries in 2000 (table 4).43 and 44 In total, an estimated 163 756 Filipino nurses were working abroad in 2000.45 The number of Filipino nurses who migrate annually (to all destinations) increased from 7683 in 2000, to 13 014 in 2009,46 with Saudi Arabia, the USA, the UK, and the United Arab Emirates being the top destinations (figure 4). Migration is in large part driven by the substantial wage premium associated with overseas employment—a nurse in Manila earns US$58–115 per month, compared with $5000 a month in the UK or USA.47

두 가지 종류의 의료인력 이주가 있는데, 임시이주는 시간이 제한된 work visa를 통해 나가는 것으로 주로 중동이나 ASEAN국가에서 관찰된다. 반대로 영구이주는 이런 work contract를 따르지 않는 것으로 1990년대 초반에 필리핀 간호사의 영구이주가 비자조건이 완화되면서 심해졌다. 이러한 두 가지 이주 형태가 갖는 함의는 서로 다른데, 임시이주는 결국 본국으로 돌아올 것이고 본국으로 돈을 송금하는 경우도 더 많다.

There are two types of health-worker migration. Temporary migration refers to health workers who have time-restricted or contract work visas as are often seen in Middle Eastern and ASEAN countries. Conversely, permanent migration refers to those whose stay in destination countries does not depend on work contracts. In the early 1990s, permanent migration of Filipino nurses was driven by relaxation of resident visa requirements, particularly in the USA and the UK. Temporary and permanent migration have differing implications for the health system, since temporary migrants are more likely to return to work in their home country and to send remittances to family than are permanent migrants.

해외로 이민을 가는 것의 한 가지 장점은 본국으로 송금하는 것인데, 이러한 송금을 통해서 본국에 있는 가족의 경재 상태를 향상시킬 수 있고, 지역 경제에도 긍정적 효과가 있다. 그러나 이주가 갖는 부정적 측면을 보면, 예를 들면 필리핀에서 미국으로 나가는 간호사의 수요가 늘어나면서 필리핀 의사가 간호사가 되기 위해서 다시 수련을 받는 경우가 생기고 있다. 2001년과 2003년에 각각 2000명, 3000명의 의사가 nurse medic으로서 재수련을 받았다. 

One of the potential benefits of migration of health workers are the remittances sent home by migrants to their families. Such income can improve the economic status of migrant families while also having a positive effect on the local economy.48 But migration also has potential downsides. For instance, the recent upsurge in the demand for nurses abroad and opportunities for permanent emigration to the USA resulted in Filipino doctors retraining as nurses in order to seek overseas employment as nurses.48 Roughly 2000 and 3000 doctors in 2001 and 2003 were retrained as so-called nurse medics.48 These nurse medics sought to take advantage of opportunities open to nurse migrants.

필리핀의 이러한 경험은 국제적 수요와 국내 수요-공급의 복잡한 관계를 보여준다. 2009년의 세계 경제 위기로 인해서 해외로 이주하는 간호사의 수요가 줄었다. 간호사들은 해외로 지원하기 전에 주로 병원에서 2~3년간 근무를 해야 하기 때문에 이 시기가 병목구간으로 작용했다. 

The experience in the Philippines illustrates the complex interactions between global demand and domestic supply and demand. By 2009, the global recession had led to a drop in international demand for migration of nursing staff (including sharp reductions in work visas for entry into the USA), even as nursing schools continued to produce new graduates. Nurses are typically required to have a licence as well as 2–3 years' experience in a referral hospital before they can apply for overseas employment visas, and this requirement has emerged as a major bottleneck. 

필리핀 간호사 수출

In 2008, the Philippines Overseas Employment Administration reportedly had 20 000 unfilled job orders for nurses to the Middle East, Singapore, and Europe.49 Thus, whereas some hospitals in the Philippines have reportedly had to close wards because of loss of experienced staff and sometimes entire teams, other hospitals have a backlog of junior nurses seeking internships. A survey of 200 public and private hospitals found that administrators had little difficulty recruiting nurses with less than a year's experience, but had more difficulty recruiting experienced nurses, particularly in private hospitals, which offered lower wages on average than did public hospitals.50 The Philippines is thus hampered by its low capability to employ the new nurses it has produced, and is now in surplus.

인도네시아 역시 많은 간호사를 수출하고 있다. 경험 많은 간호사와 조산사의 유출 문제가 심각하다.

Indonesia also exports many nurses. Muslim countries such as Saudi Arabia, the United Arab Emirates, Malaysia, and Singapore are the main destinations. Few data are available, however, either for migration or employment in the domestic private sector. With lower health-worker production capacity per population than that of the Philippines, outmigration of experienced and highly skilled nursing and midwife staff creates great challenges for the system, and exacerbates the problems of shortage and quality of care in the Indonesian health system.32

싱가폴은 동남아시아의 주요 의사 수입국이다. 2009년에는 1000명의 외국 의사를 모집하는 것을 목표로 삼았고, 보건부에서는 싱가폴로 이민왔을 때의 혜택을 광고하고 있다. 최근의 통계를 보면 2/3의 싱가폴 의사, 그리고 공공부문의 1/3정도 의사가 외국에서 교육받은 의사이다. 싱가폴은 또한 간호사도 외국에서 수입하고 있다.

Singapore is the major importer of doctors in southeast Asia. In 2009, a recruiting target was set of up to 1000 foreign trained doctors. The Ministry of Health has a webpage to advertise the benefits of migration to Singapore. Recent statistics show that two-thirds of doctors in the country and a third of doctors in the public sector are foreign-educated (including those Singaporean doctors who trained abroad).14 Singapore also imports nurses from other countries—an estimated 30% of all nurses working in the country are foreigners.

최근 여러 국가들이 bilateral 혹은 multilateral agreement를 맺는 경우가 많아서, 영국과 필리핀이 2002년부터 2006년까지 225명의 간호사에 대한 계약을 맺었고, 일본과 캐나다도 필리핀과 인도네시아와 계약을 맺었다.

Recent years have seen a tendency for recruitment patterns to shift from individual applications or institution recruitment to bilateral and multilateral formal agreements between origin and destination governments. For instance, the Philippines and Indonesia have entered into bilateral agreements with several countries. The UK–Philippines agreement, signed in 2002, resulted in the recruitment of 225 experienced Filipino nurses from 2002 to 2006. The agreement came to a close in 2006, when the UK declared that nurse shortage was no longer a concern.51 Japan and Canada also entered into agreements with the Philippines and Indonesia to provide skilled nurses.

the ASEAN Framework Agreement on Services

At the regional level, the ASEAN Framework Agreement on Services, signed in 1995, progressively liberalises trade in services, with health being one of the 11 priority sectors. In 2001, members began negotiating mutual recognition arrangements to facilitate flow of professionals, as agreed by the Framework Agreement, with the expectation of achieving free flow of health workers by 2010. The agreements call for mutual recognition of qualifications and professional licences across ASEAN countries. A mutual recognition arrangement on nursing services was signed in 2006, followed by an agreement for medical practitioners in 2008. The diversity of the ASEAN region, including differences in the quality of education and training, licensing requirements, language, and cultural dimensions of daily medical practices between countries, makes implementation of these agreements challenging.15 These barriers, as well as additional requirements of 3 years of work experience for nurses and 5 years for doctors, have posed difficulties for the free flow of health professionals in southeast Asia.

Discussion

다섯 개 ASEAN국가는 WHO의 기준에 미달하고 있다. 태국과 말레이시아는 경제수준에 비추어 의료인력 밀도가 낮으며, 필리핀과 싱가폴, 브루나이는 밀도가 높다.

Southeast Asian countries face diverse health workforce challenges. Although there is not an aggregate shortage of health workers at the regional level, five countries in the ASEAN region (Indonesia, Vietnam, Laos, Cambodia, and Myanmar) fall below the WHO threshold of 2·28 doctors, nurses, and midwives per 1000 population. Thailand and Malaysia have low densities of health workers in view of their level of economic development, whereas the Philippines, Singapore, and Brunei have high densities.

국제 기준에 비교를 하지 않더라도, 이 지역의 국가들은 qualified and motivated 의료인력을 더 양성해야 할 압박을 받고 있다. 그러나 많은 동남아 국가에서 경제적 능력이 공공부분 인력고용 확장의 한계로 작용하고 있고, 졸업한 의사와 간호사가 일자리를 찾지 못하고 있다. 따라서 의료인력의 양성과 배치의 연계를 효과적, 계획적으로 하는 것이 중요하다.

Irrespective of how health-worker density relates to international norms, most countries in the region face pressures to increase the availability of qualified and motivated health workers in order to meet the needs of the population. Increased production of health workers clearly has an important part to play in addressing this challenge. However, in many southeast Asian countries, fiscal capacity restricts the scope for expansion of public-sector employment, and many graduating doctors and nurses are not able to find jobs in the health sector. This problem points to the need to strengthen the link between production and use or deployment of trained workers through health workforce planning and effective engagement (and regulation) of medical education providers.

이러한 인력부족에 대응하는 한 가지 방법은 일부 임상기능을 더 낮은 레벨의 인력에게 맡기는 것이다. 이는 taskshifting이라 불리는 것으로, 비용-효과적인 방법이며 이를 통해서 지역사회 수준 의료인력에 대한 의존을 높일 수 있기도 하다.

One approach to improving the availability of staff with limited resources is to shift some clinical functions and other responsibilities to lower level staff. This process—often referred to as taskshifting or substitution—has been found to be a cost-effective solution to increase access to services in various settings, although the evidence from middle-income countries is scarce.52, 53 and 54 Taskshifting can also entail increased reliance on community-level workers, such as the community midwives that are widely deployed in Myanmar, which might be particularly helpful in contexts with underuse of facility-based services.

그러나 의료인력의 밀도가 높아졌다고 해서, 의료서비스 공급가능성으로 이어지는 것은 아니며, 이는 특히 빈곤층이나 농촌 지역 인구에서 심하다. 많은 국가들이 배치와 유지의 문제를 안고 있으며, 공공부문에서 그러한 문제가 더 심하다. 몇몇 국가에서는 이러한 문제를 일부 해결하는데 성공한 바 있으나, 여전히 이러한 문제는 심각하다. 또한 이러한 경우에 한 가지 접근법만을 사용하는 것 보다 여러 접근법을 동시에 활용하는 것이 좋은 것으로 알려져 있다.

However, a high health workforce density does not necessarily translate into improved availability of services, in particular for poor and rural populations. As elsewhere in the world, many countries in southeast Asia face persistent challenges in deployment (and retention) of doctors, nurses, and midwives to rural and remote areas, resulting in a high degree of inequality in the distribution of the health workforce (particularly doctors) across provinces and regions. Many countries are also having difficulty retaining staff in the public sector, with potentially adverse implications for the availability of services for the poor and near-poor populations, who tend to be less likely to use private formal providers. Some countries in the region have had success in addressing these challenges (panel 2), but imbalances remain substantial. Although there are significant gaps in the evidence base with respect to how best to address these imbalances, there is growing consensus on the mix of approaches that countries should consider to improve deployment and retention.59 and 60 Experiences in specific countries show that comprehensive strategies are more effective than a single approach (panel 2). However, countries need to be able to respond to changing situations to ensure sustainable outcomes.

의료인력의 밀도가 낮다는 것이 인구보건요구를 달성하는데 유일한 제한사항은 아니다. 이런 동남아 국가에서 의료서비스의 이용 자체가 낮은데, 의료인력이 부족한 것이 한 가지 이유일 수는 있지만, 서비스의 질이 낮은 것, 경제적 장벽, 그 외 다른 요인들도 중요하다. 

Of course, low health workforce density is by no means the only constraint to meeting population health needs. In many of the low-income countries in southeast Asia with low health-worker density (critical shortage), use of health services is often also low. Scarcity of human resources is one factor in this situation, but poor-quality services, financial barriers, and other factors might be more important. Hence, efforts to expand the health workforce in these contexts need to go hand-in-hand with complementary measures to reduce financial and other barriers to service use.

We have also drawn attention to the growing trade in health services, and the significance that this trade has for health systems and policies for human resources for health in the ASEAN region. High-income and middle-income countries are participating more actively in this trade than are those with low incomes, with flows of both patients and health workers. Indonesia and the Philippines both export many doctors and nurses, although from very different starting points in terms of the organisation of medical education and training. Thailand and Malaysia are actively involved in provision of health services to foreign patients, but have little involvement in the export of health personnel. Singapore and Brunei are the main importers of foreign health workers, and Singapore is also engaged in medical tourism. Conversely, low-income countries in the region (Cambodia, Laos, Myanmar, and Vietnam) are not engaged extensively in the trade in health services, except with respect to wealthier patients seeking care in middle-income and high-income countries.

- Trade는 점차 늘어날 것으로 예상됨. 

Trade in health services is likely to continue to grow. Many countries are actively promoting medical tourism. For instance, the Thai Government is promoting Thailand as a major medical hub in Asia as part of an effort to expand and diversify exports. Moreover, the ongoing process of regional (ASEAN) integration, which has already led to mutual recognition arrangements for three groups of health professionals (doctors, nurses, and dental practitioners) and other measures to facilitate the movement of labour, is likely to result in increased movements of human resources for health within the region. However, in practice, language skills and technical competence will remain key criteria for potential employers, so the freedom to move will not necessarily translate into employment opportunities for health workers, in particular those from low-income countries.

- Medical Tourism이 장점도 있을 수 있으나

Medical tourism and remittances from overseas workers can generate substantial economic benefits, 

and potentially generate broader benefits for patients and health workers through investments in facilities and health-worker training, increased competition, and strengthened accreditation and quality standards. 

- 그러나 단점도 많음. : 의료인력 양성과 고용 패턴에 영향을 주며, 불평등을 심화시키고, 두뇌유츨이 생기고, 첨단 기술이 도입되는 것은 지속가능하지 않음

But these benefits are by no means automatic, and trade in health services also has many potential downsides. 

Although the evidence suggests that trade in health services is not the main driving force behind health-worker shortages or maldistribution in the ASEAN region, this trade clearly affects health-worker production and employment patterns, particularly in middle-income and high-income countries. Migration can deplete the domestic stock of health workers, particularly specialist doctors and experienced nurses, with effects on the quality and availability of services. Similarly, medical tourism can exacerbate inequalities in access to health care because of a brain drain of highly skilled health professionals from public to private hospitals and from rural to urban areas.37 Medical tourism can also lead to a rapid expansion of high-end, technology-intensive health care, which might not be sustainable over time and can distort practices and priorities in the broader health system.

- Trade에 대해 가능한 대책들 : Codes of practice(본질적으로 자발적임), Bilateral agreement

Although the growing trade in health services is clearly an important policy challenge for countries in the region, how countries should respond to this challenge is less clear. What can countries do to maximise benefits from the trade in health services? Can the risks be mitigated or managed? How should benefits, risks, and the interests of sending and receiving countries be balanced? So far, the evidence base to answer these questions is weak, in part because the way in which trade in health services affects health systems is highly context-specific. With respect to movement of health workers, banning of migration is widely recognised as neither possible nor ethical.61 One route to addressing this challenge has therefore been to establish codes of practice for the international recruitment of health personnel. 

One such code of practice was adopted by the 2010 World Health Assembly, which aims to lay down principles for ethical recruitment of health personnel to maximise benefits and mitigate negative effects on countries while maintaining the rights of migrant health personnel.62 

However, the code is voluntary in nature, and in view of the complexity of migration as an international occurrence, its implementation will inevitably be challenging.

Another route to address the challenge of migration is through bilateral agreements covering agreed numbers of migrants, but potentially also allowing for technical assistance and capacity building—measures that should allow the return of migrants to their home countries to train and to teach, provide compensation where necessary, and forge partnerships between hospitals from sending and receiving countries.63 Experiences from other regions suggest positive results. 

For example, the UK and South Africa signed a memorandum of understanding in 2003 that established time-limited placements between countries and a framework for ethical recruitment of health personnel. This memorandum has resulted in a decrease in the number of South African nurses and midwives working in the UK, and the twinning policy has improved quality of health personnel in South Africa.63

- Medical Tourism에 대해 가능한 대책들 - Trade보다는 경험이 적음

So far, there has been less experience with similar measures implemented to balance the benefits and risks associated with medical tourism—for example, through local agreements, agreements between the public sector and providers or associations engaged in the provision of services for international patients, or codes of good practice. Such measures could have potential, in particular if accompanied by strengthening of quality and accreditation throughout the health system, to stimulate transfer of capacity and good practice from private providers through partnerships with medical education institutions, and to reallocate benefits from trade in health services to public sectors, especially to rural areas that might have been affected by internal brain drain.

More generally, the effects of trade in health services on health systems hinge on how the supply of health workers responds to a growth in migration and medical tourism. The supply of health workers, in turn, depends on how the health education system is organised and regulated. Countries in southeast Asia offer very different models in this respect. The rapid growth of export-oriented private training in the Philippines and Indonesia has mitigated the effect of migration on the total stock of health workers, but poor regulation of private training has compromised quality and contributed to overproduction of health workers with scarce employment prospects. Thailand on the other hand has no policy of training for the purposes of working abroad, and the private sector plays a very small part. Strong oversight is needed to ensure quality and to regulate output in the Philippines and Indonesia, whereas training policies especially for highly specialised staff in Thailand might need to take into consideration the projected growth of medical tourism.

Human resources for health in southeast Asia: shortages, distributional challenges, and international trade inhealth services.