Slowing the brain drain: FAIMER education programs

WILLIAM P. BURDICK, PAGE S. MORAHAN & JOHN J. NORCINI 

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

Introduction

- 개발도상국에서 의사인력의 유출(migration)은 세계 곳곳에서 심각한 의료인력부족을 낳고 있음.

- Migration의 충격 : 교육받은 시민의 손실, 의료공금자의 손실, BME, GME에서 연구역량과 교사의 손실

- 두뇌유출을 늦추는 것은 복잡한 노력이 필요하나 다양한 노력을 통해서 줄여나갈 수 있다.

- 양질의 미국 의학교육은 GME단계에서 많은 인력을 끌어당기고 있다. 그리고 이들은 수련을 마친 후에도 미국에 남는 경우가 많다.

- FAIMER는 ECFMG(Educational Commission for Foreign Medical Graduates)의 supporting corporation으로서 지난 5년간 교수개발 프로그램을 만들어서 해외 의학교육을 강화시키고, 진로발전을 도움으로써 의료인력이 부족한 국가의 공급을 늘리는데 기여하고자 했다.

Migration of physicians from developing countries has created serious shortages of medical manpower in many parts of the world (Marchal & Kegels, 2003; Mullan, 2005). The impact of migration on donor countries includes loss of educated citizens, healthcare service providers, research capacity and teachers at the undergraduate and postgraduate medical level (Aluwihare, 2005). Slowing the brain drain is a complex endeavor but developing skills, creating professional networks and enhancing opportunities for career advancement of physicians may be an important element in diminishing out-migration. The attraction of high-quality US medical education, and especially graduate medical education, has drawn thousands of foreign physicians to postgraduate training programs in the US (Whelan, 2002). After training is complete, many of these individuals are granted visa waivers by federal or state agencies and stay to practice medicine in the US. The Foundation for Advancement of International Medical Education and Research (FAIMER), a supporting corporation of the Educational Commission for Foreign Medical Graduates, has created faculty development programs over the past five years to strengthen medical education and career advancement for medical educators overseas, thus supporting the expanded production of physicians in those countries where there is an undersupply.

- FAIMER의 교육 프로그램은 세 부분으로 이루어져 있다. 

FAIMER's education program has three components. 

• The FAIMER Institute, started in 2001, awards a two-year fellowship focused on educational leadership and methodology. It consists of two brief residential experiences in the US integrated with distance learning (Norcini et al., 2005). 
• The International Fellowships in Medical Education (IFME) program is an advanced-level fellowship that funds selected graduates of the Institute to obtain a master's in medical education at academic institutions around the world. 
• Most recently, FAIMER has begun to develop regional institutes in other parts of the world based on the principles embedded in the original FAIMER Institute. The purpose of this paper is to present the goals of the program, describe the components in detail, present data concerning their efficacy and outline plans for the future.

Goal

- FAIMER프로그램의 최종 목적은 개발도상국에 지속가능한 의학교육Discipline을 구축하여 해당 국가의 의학교육을 가능하게 하는 것이다. 

- 강력한 의학교육 시스템의 효과는 몇 가지로 나눠볼 수 있다. (BME, GME, CPD)

The overarching goal of the FAIMER education program is to strengthen medical education and help build a sustainable discipline of medical education in developing countries. The effects of a stronger medical education system are several. 

• At the undergraduate medical education level, there is the possibility that it may attract higher quality students to the field and improve their rate of retention; increased attraction and retention has been shown in US medical schools (Milbank, 2005). 
• The development of local high-quality postgraduate education will enhance opportunities for completing medical training in their home country. 
• Strong systems for undergraduate and postgraduate education are likely to create an impetus for continuous professional development, further increasing the attractiveness of practicing medicine in their home country. 

- 개발도상국에게 의학교육 원칙(discipline of medical education)을 확립하게 하는 전략으로는 다음과 같은 것이 있으며, 최종적인 효과는 양질의 의사를 양성하여 그 지역 인구의 건강을 증진하는 것이다.

Strategies for facilitating development of the discipline of medical education in developing countries include: 

• creating a critical mass of educators and supporting the interaction of these individuals, 
• providing access to educational resources, 
• developing leaders in medical education, and 
• encouraging and facilitating scholarly work in this domain. 

The net effect of these efforts should be to increase the production of high-quality physicians likely to serve populations in their country of training, thereby improving the health of the population.

- FAIMER의 교육 프로그램은 남아시아, 아프리카, 남아메리카를 주요 대상으로 하며, 이들 대상이 선정된 주요 근거는 다음과 같다. 그러나 이들 지역 외 지역에서도 매년 지원자가 있다.

FAIMER's educational programs currently focus on South Asia, Africa and South America. These regions were chosen based on 

• (1) need, 
• (2) stability and accessibility, 
• (3) the capacity to use and sustain the resources FAIMER contributes and 
• (4) the number of former Fellows in the area. 

Applications from other regions, however, are accepted each year.

FAIMER education programs

FAIMER Institute

FAIMER Institute는 gateway 프로그램으로서, 여기에 지원하는 사람들은 영어를 유창하게 할 수 있어야 하며, 지원 시점, 합격 시점, Fellowship진행 과정 동안 본국에서 거주하며 근무중이어야 한다. 이 지원의 핵심 요소는 교육과정혁신프로젝트(Curriculum innovation project)이며, 지원자가 이 프로젝트를 작성하면 단/장기 적으로 평가받게 된다.

The FAIMER Institute is the gateway program for education activities. Applicants for the Institute, who are required to speak English at a high level of proficiency, must reside and work in their home countries at the time of application, acceptance and duration of the Fellowship award. Central to the application is a curriculum innovation project in which the applicant describes the purpose of the innovation, how the change would be implemented, and how the success of the project would be evaluated in the short and long term. The curriculum innovation project becomes the vehicle for learning about concepts of leadership and education methodology.

2년짜리 프로그램인 FAIMER Institute는 매년 16명의 참가자가 있으며 4세션으로 진행된다. 두 세션은 미국에 머물며 진행되고 두 세션은 원거리 학습을 한다.

The two-year program, with 16 participants each year, includes four sessions—two residential in the United States and two distance learning. 

세션1 : 첫 번째 세션은 세 가지 주제로 구성되어 있다.

During Session 1, a three-week residential component, there are three curriculum strands. 

Fellows acquire basic skills in medical education, including large-group teaching, problem-based learning, student assessment and program evaluation. 

Fellows also gain skills in leadership and management. 

These include: assessment and understanding of their own leadership style and how to use that insight when working with others, project management tools, managing change processes, handling conflict, understanding group dynamics, the nature of high performance teams, and appreciative leadership (Dorsey, 2000; Bushe, 2001; Burns, 2003). 

The third strand encompasses building a strong community of practice (Wenger et al., 2002). Fellows are involved in a variety of methods to create community, including sharing their professional ‘stories’ (Wheatley, 2005) learning about the concept of social capital and how communities of practice are built and maintained (Baker, 2000; Abrahamson, 2004) and experiencing the role of co-mentoring. To make learning concrete and meaningful, the Fellow's project is the focus of special attention throughout the session. Individual, small-group and large-group discussions are used, as is feedback from peers and experts. The goal is for the Fellows to refine their projects and be ready to implement them on their return home.

세션2 : 첫 번째 미국내 세션이 끝나면, 연수생들은 본국으로 돌아가서 프로젝트를 수행하면서 두 번째 세션에 참가하는데 이 때는 인터넷을 활용한 멘토링과 원거리 학습 프로그램이 이용된다.

After the first residential session, the Fellows return home to conduct their projects and participate in Session 2, a mentoring and distance-learning program on the Internet (Mentoring and Learning Web, or ML-Web). During Session 2, they are co-mentored by a second-year fellow and a Global Faculty Adviser (selected from previous graduates). 

세션3 : 1년차의 마지막 2주를 다시 미국으로 돌아와서 advanced 과정을 밟고 co-mentoring을 진행할 새로운 1년차 연수생과 연결된다.

The Fellows return to the US for approximately two weeks at the end of the first year for workshops on advanced leadership, management and education issues, and to connect with the first year Fellows they will be co-mentoring (Session 3). 

세션4 : 세션2의 ML-Web을 다시 활용하게 되며 학술업적을 이뤄야 한다.

In Session 4, second-year Fellows participate in the ML-Web, developing required scholarly output and co-mentoring a first-year Fellow.

FAIMER Regional Institutes

FAIMER Institute의 참가자들이 residential session 기간동안에 미국에 와야 하는 것과 달리 FAIMER RI는 개발도상국의 의과대학에서 진행되며 주변 지역에서 참가자들이 온다. 

While participants in the FAIMER Institute come to the US for residential sessions, the FAIMER Regional Institutes are conducted at medical schools in developing countries for participants from the surrounding area, using principles embedded in the FAIMER Institute. 

지난 3년간 다양한 지역 프로그램(local initiative)가 있었다. 하나는 2005년 7월에 시작했고, 다른 하나는 2006년 1월에 시작하였으며, 나머지 두 개는 현재 개발중이다.

A variety of local initiatives have been conducted over the past three years. One Regional Institute started in July 2005, another began in January 2006, and two others are currently in development. The experimental and iterative growth process involves: 

(1) full respectful partnership with the local organizers, 

(2) co-creation of a curriculum that fits the local context and needs, 

(3) local capacity regarding resources for all logistical issues, 

(4) commitment by local organizer to facilitate FAIMER networking in the region through participation of FAIMER Institute graduates as faculty, and 

(5) dual learning by FAIMER and the local organizing entity that informs future efforts (Plsek, 2001).

RI는 FAIMER Institute 교재를 활용하며, 미국에서 FAIMER Institute를 성공적으로 이수한 해당 지역의 교수의 리더십에 따라 진행된다. 교수진(faculty member)은 주로 그 지역에서 오며, 여기에 추가로 일부 해외 교수진이 추가된다. 첫 몇 년간은 자금을 지원해주며 그 이후는 해당 지역 참가자와 의과대학이 비용을 부담할 것으로 기대한다.

Regional institutes are created using FAIMER Institute materials, with leadership by local faculty who have completed and excelled in the Institute in the US. Faculty members are predominantly from the region, with addition of some international faculty. Funding is provided for the first several years of operation, with the expectation that local participants and their medical schools will provide ongoing funding in subsequent years.

Other regional initiatives have ranged from co-creation of medical education skill-building workshops for clinical skills assessment to co-creation of medical educator leadership and project-management workshops. These involved partnership with FAIMER faculty for curriculum design, and travel of FAIMER faculty to participate in the workshops. FAIMER faculty have also facilitated individual and collaborative medical education scholarship development through on-site consultation.

The first regional institute was started in July 2005 in Mumbai, India. 

Seth Gordhandas Sunderdas Medical College (GSMC) was selected because of the presence of an existing faculty development program, the involvement of an Institute graduate, the support of the medical school leadership, and the institution's outstanding reputation. The GSMC-FAIMER Regional Institute is being created from the existing faculty development program, which was approximately three days in duration. The first iteration of the regional institute transformed it into a two-year program with two five-day residential sessions, a curriculum innovation project and a distance learning component. Because of geographic proximity, several brief interim meetings, as well as on-site consultations, have been possible. The residential components will be lengthened gradually until they are each about 10 days in duration.

Education methodology workshop topics during Session 1 of the GSMC-FAIMER Regional Institute in 2006 have included the teaching and learning process, group dynamics, writing objectives, small- and large-group teaching, use of audiovisual tools and student assessment, as well as multiple-choice question formulation. Leadership and management topics have included team building, networking and change management. Significant time has been allocated to project management and educational project design, especially as related to participants’ curriculum innovation projects.

The Regional Institute in Ludhiana, India began January, 2006 at Christian Medical College—Ludhiana (CMCL). 

CMCL-FAIMER Regional Institute is under the leadership of a former Institute fellow, and includes participants from the Punjab, but also from the New Delhi, Mumbai and Bangalore areas. Faculty are from the home institution, the South Asia region, as well as from other international institutions. Development discussions are underway for additional regional institutes in Brazil and South Africa, as well as other parts of South Asia and Africa.

International Fellowships in Medical Education

승진에 필요한 연구와 학문을 위해서 뿐만 아니라 더 깊은 지식을 위해서도 고급학위(advanced degree)가 중요하다. 그러나 교육 관련 고급학위(advanced degree)가 없는 경우에 실험 또는 역학 연구 학위를 받아야 하고, 이로 인해 애초에 교육에 관심이 있었던 사람들이 멀어지게 된다.

Advanced degrees are useful for developing in-depth knowledge as well as skills in research and scholarship, which are essential for promoting a cadre of professionals in any field. In medical schools around the world, an advanced degree beyond the initial clinical medicine degree is often a prerequisite for faculty promotion. If advanced degrees in education are not available, aspiring faculty seeking promotion must pursue academic work in other areas such as bench research or epidemiology, distracting them from a possible career in medical education.

FAIMER Institute 와 Regional Institute의 졸업생은 IFME에 지원할 수 있으며, 세계 어디에서든 입학하여 원격교육을 통해 석사학위를 받을 수 있다. 연수생들은 advanced standing을 받을 수 있으며, 학위를 받을 때 까지는 3년이 걸린다. 모든 프로그램은 약간의 residential component가 있다.

Institute and regional institute graduates are eligible to apply for an International Fellowship in Medical Education award, which supports matriculation at an approved master's in education program anywhere in the world using a distance-learning format. Fellows receive slightly advanced standing for their work at the Institute, and they have three years to complete the degree. All programs have a modest residential component so that participants can create better connections with their fellow students and faculty.

Evaluation of the FAIMER education programs

FAIMER 교육 프로그램의 평가는 프로그램 평가의 logic model과 Kirkpatrick의 모델을 이용하여 정량적, 정성적 접근을 같이 하였다. 즉각적 반응은 각 워크숍 직후에 설문을 통해 평가하였으며, 지식과 태도의 변화는 'retrospective pre-methodology'를 사용하엿다. 행동의 변화는 세션3 이후 주기적으로 심층 면접을 시행하여 평가하였다. 

Evaluation of the FAIMER education programs combines qualitative and quantitative approaches, and is organized using the logic model of program evaluation (WF Kellogg) and Kirkpatrick's levels of impact (Kirkpatrick, 1994). Immediate reaction to sessions is assessed through detailed questions concerning the quality of each workshop. Change in knowledge and attitudes is assessed using ‘retrospective pre-methodology’ (Skeff, 1992). Change in behavior, as well as knowledge and attitudes, is assessed through in-depth interviews at the end of Session 3 and periodically after the conclusion of the program. Data are collected and analysed by an independent team from the University of New Mexico Office of Program Evaluation, Assessment and Research.

retrospective pre-data의 분석으로부터 모든 여덟 개 의학교육 분야에 대해서 통계적으로 유의미한 효과가 있었음을 확인하였고, 여섯 개의 리더십과 경영 분야에서 통계적으로 유의미한 효과가 있음을 확인하였다. 

Analysis of the retrospective pre-data from the first three classes has shown large, statistically significant effects in all eight areas of medical education (international medical education, educational methods, assessment of student performance, educational program evaluation, educational projects, international medical education day, distance education, qualitative evaluation methods) and all six areas of leadership and management (change theory and management, personal professional development, project management, advanced leadership, whole systems models to sustain change, electronic learning and management). These indicate the impact on Fellows’ perceptions of the importance of the areas, as well as on their self-ratings of growth in knowledge, skills and attitudes before and after the Institute.

의학교육과 리더십의 지식과 술기 향상 외에도, Institute의 주요 목적 중 하나는 개발도상국에서 의학교육의 교수개발이 중요한 원칙(recognized discipline)이 되도록 하는 것이었다. 

In addition to increasing knowledge and skills in medical education and educational leadership, a major goal of the Institute is to facilitate development of medical education as a recognized discipline in developing countries. 

Fellows are developing both individual and collaborative scholarship. In addition to an almost 100% rate of return and retention for Institute Fellows (45/46 from the first four Institute classes), they are growing professionally at their institutions. 

• Of the 45 Fellows who have completed the program, 
• 16 have made a total of 31 presentations at international meetings; 
• six have produced 15 peer-reviewed publications; and 
• 13 grants and 15 awards in medical education have been obtained. 
• Two Fellows have obtained an advanced education degree, and 
• 14 have received an academic or administrative promotion to associate or full professor, department chair, sub-dean or dean.

Institute의 또 다른 주요 목표는 지역 수준, 국제적 수준에서 의학교육자들의 네트워크를 구축하는 것이었다.

Another major goal of the Institute is to foster development of close regional and international networks of medical educators—a cohesive international community of medical education practice. Analysis of their networks prior to the Institute has shown that the classes of 2001 to 2004 had professional networks that were initially small in number, dense (most members of their networks knew each other) and near by geographically. After the Institute, the Fellows’ professional networks had become larger, less dense and more diverse geographically.

Future plans, implications for slowing the brain drain

Our experience emphasizes that development of an international program with high-quality regional medical educational leadership institutes must take place slowly and deliberately, and be adaptable to emerging opportunities (Baker, 2000; Buchanan & Booker, 2004). Starting with an existing faculty development program, the lead time for development of a new regional institute is approximately 1–2 years. Evaluation data from the first regional institutes will need to be collected for several years before meaningful inferences can be made and used for improved development, implementation, model distribution and evaluation of other regional institutes. We anticipate that several more regional institutes and initiatives may be developed each year.

As regional institutes become stronger, we anticipate a shift in the emphasis of the FAIMER Institute. The program in the US may become more of a faculty-development leadership institute, emphasizing the skills necessary to design and manage faculty development programs, and regional institutes in particular. The central program may increasingly facilitate collaborative scholarly endeavors with Fellows around the world, using the extensive FAIMER research expertise for research design, data collection and analysis.

The field of medical education in developing countries will mature as a critical mass of skilled, internationally recognized medical educators evolves through initiatives such as FAIMER's faculty-development opportunities and facilitation of scholarly output. Increased feasibility and attractiveness of developing as a medical educator in one's home country may help slow the medical faculty brain drain.

Slowing the brain drain: FAIMER education programs.

Dropout Rates in Medical Students at One School Before and After the Installation of Admission Tests in Austria

Gilbert Reibnegger, DSc, Hans-Christian Caluba, Daniel Ithaler, Simone Manhal, Heide Maria Neges, and Josef Smolle, MD

2002-2003학년도에 오스트리아의 의학교육에는 근본적 변화가 생겼다. 전통적인, 학문 중심의 교육 프로그램이 근대적인(modern), 주제별(theme-based), 학위수여(diploma-granting) 교육과정으로 변한 것이다. 오스트리아에 있는 모든 세 개의 공립 의과대학이 이 변화를 수용했으나, 각각의 대학은 세부적인 사항에 대해서는 학교별 강점과 선호에 따라 자율적으로 조정하였다.

In academic year 2002–2003, medical education in Austria changed in a fundamental way. The traditional, discipline-oriented study program was transformed into a modern, theme-based, diploma-granting curriculum with a timely, module-track structure. Although all three public medical universities in Austria (Medical University of Vienna, Innsbruck Medical University, and Medical University of Graz) adopted this reform in general, each university was free in establishing the details of its curriculum according to its specific strengths and preferences.

Background

Graz의과대학 교육과정

The Medical University of Graz curriculum

Graz의과대학의 교육과정은 처음부터 전임상 주제와 임상 주제를 통합하는 형태였으며, 조기에 환자 경험을 쌓는 것은 사회적, 의사소통 능력 뿐만 아니라 신체검진 능력 향상에도 도움이 된다. 또한 과학적 연구에 대한 교육도 강화했으며, 새롭게 설계된 'clinical year'가 역시 교육과정의 특징이다.

The reformed curriculum at the Medical University of Graz 1 integrates preclinical and clinical topics from the beginning. Early patient contact strongly enhances training in physical examination skills as well as social and communication skills. In addition, better education in scientific research matters and a newly designed “clinical year” are the hallmarks of the new program. The curriculum is designed to be completed in six years.

처음의 두 학기는 "첫 부분"으로서 의학 맥락 속에서 기초과학을 주로 배우게 된다. "두 번째 부분"은 2학년부터 5학년까지로, 의학지식의 기초, 정상과 병리상태, 형태학, 다양한 의학/임상 학문 등등을 배우게 된다. 첫 번재와 두 번째 부분은 주제별로 5주간 진행되는 형태이다. 30개 모듈 중에서 25개 모듈은 의무이며, 5개 모듈은 선택할 수 있다.

The initial two study semesters, the “first part of study,” are dominated by the basics of natural sciences in a medical context. The “second part of study,” years 2 through 5, is devoted to the fundamentals of medical knowledge, including normal as well as pathological function and morphology and the various medical and clinical disciplines. The first and second parts of study are organized in theme-centered modules lasting five weeks each. The modules are accompanied by vertical “tracks.” In tracks, specific knowledge and skills are taught during consecutive study years. Students choose 5 out of the required 30 modules from a broad offering of elective modules; 25 modules are obligatory for all students.

6학년에는 학생들은 다양한 임상 현장에서 임상현장의 일상에 참여하게 되며, 전문적인 임상 교사(expert clinical teacher)에 의해서 관리감독을 받게 된다.  또한 6학년 기간에 5주는 general practitioner의 office에서 보내게 된다.

In year 6, students participate in the daily clinical routine at different training sites and are constantly guided and supervised by expert clinical teachers. Additionally, during the course of year 6, students also spend five weeks in a general practitioner's office.

오스트리아의 의과대학 입학

Medical school admissions in Austria

일반적으로 오스트리아 대학은 'open admission'을 따라왔다. 즉, 고등학교를 성공적으로 마친 학생은 누구나 자신이 원하는 어떤 대학에든 입학할 수 있다는 것이다. 그러나 의과대학에 있어서 이러한 '개방입학(open admission)'은 상당히 만족스럽지 못한 결과를 가져왔다. 예컨대, Graz의과대학의 경우 의과대학 신입생은 600~800명으로 매년 다르며, 이 숫자는 교수 뿐만 아니라 시설 측면에서 학교의 수용능력을 넘어서는 것이다. 따라서 학습 환경이 좋지 못하고, 의욕이 꺾인 학생과 교수들은 소규모 학습 따위는 거의 하지 않으며 대부분의 수업이 대형 강의로 진행된다. Bedside teaching도 거의 없다. 학생들은 의과대학이 6년제 교육과정임에도 평균적으로 50%(3년) 이상을 추가적으로 학교를 다니고 있으며, 약 절반의 학생은 졸업하기 전에 탈락(dropped out) 한다.

In Austria, open admission to university studies has been the rule: Everyone successfully finishing secondary school education is generally entitled to be admitted to whatever university study she or he wants. In medicine, open admission led to particularly unsatisfactory consequences. For example, at the Medical University of Graz, the average number of new medical students varied between 600 and 800 per year, substantially exceeding capacities in terms of staff as well as infrastructure. Thus, study conditions were poor. Frustrated students and faculty made do with little or no small-group lecturing, a predominance of mass lectures, and little bedside teaching, among other limitations. On average, students exceeded the scheduled study time of six years by 50% or more, and approximately half of the students dropped out before reaching graduation.

오스트리아 의과대학은 또한 오스트리아 외 국가에서도 학생을 받아왔는데, 역사적으로 오스트리아의 대학에 입학하는 다른나라의 학생들(EU 국가 포함)은 자신의 국가에서도 동등하게 대학에 입학하였다는 것을 입증하여야 한다. 그러나 유럽법(European law)에 따르면 EU국가의 모든 시민들은 오스트리아 대학에 지원할 때 오스트리아 국민과 동등한 대우를 받아야 하고, 2005년 7월 European court는 오스트리아의 외국 학생에 대한 정책이 위법이라는 판결을 내렸다. 

Austrian medical universities also admitted students from outside Austria. Historically, students from other countries—including member states of the European Union (EU)—were admitted to an Austrian university only after they proved they had also been admitted to the same course of study in their country of origin. According to European law, however, citizens from all EU member states must be treated in the same way as Austrians when applying to Austrian universities. In July 2005, the European Court ruled that Austria's policy of foreign student admission to university studies violated European law.2 

이러한 결정은 의과대학에 특히 결정적이었다. 독일은 오스트리아의 인접국이면서, 오스트리아와 같은 언어를 사용하는데, 독일에서는 30000명의 의과대학 지원자 중 8000명~10000명만 의과대학에 입학할 수 있었던 것이다. European Court의 판결 이후 세 개의 오스트리아 의과대학이 독일 학생들로 꽉꽉 찰 것이라는 우려가 상당했다. 이에 대한 대책으로서 오스트리아 법이 즉각적으로 개정되었는데, 대부분의 대학 입학에 대해서는 여전히 개방입학(open admission)으로 남겨놓았지만, 일부 학과에 대해서는 입학 시험을 도입하는 것으로 바뀌었고, 이러한 학과에는 의학과 치의학 학위 프로그램이 포함되었다. 또한 European Commission은 2007년부터 5년간 오스트리아로 하여금 학생의 정원을 통제할 수 있도록 하였으며, 대부분의 의과대학 정원은 오스트리아 국민에게 가도록 하였다. 전체 정원중 75%는 오스트리아 자국민에게 할당되었으며, 20%는 다른 EU국가, 5%는 그 외 다른 국가에게 분배되었다.

This decision was particularly important for medical universities because of circumstances in Austria's neighboring country, Germany, which shares the same language as Austria. In Germany, only 8,000 to 10,000 of the approximately 30,000 applicants for the study of medicine are admitted each year. Therefore, after the court's decision, it was feared that the three Austrian medical universities would be overwhelmed by German students. To avoid this, Austrian law was changed immediately: While admission to most university study programs remained open for all applicants having completed secondary education, admission tests were introduced to regulate access for selected studies. Among the regulated studies were the diploma programs in human medicine and dentistry. Additionally, the European Commission issued a five-year moratorium in 2007,3 entitling Austria to regulate quotas of students until 2012 to ensure that the majority of openings are reserved for Austrian citizens. Seventy-five percent of openings are reserved for applicants who completed their secondary education at an Austrian school, 20% for citizens from other EU states, and 5% for applicants of other nationalities.

Graz의과대학의 선발

Medical University of Graz admissions

2005년, Graz의과대학은 난관에 봉착했는데, 이 전 년도의 개방입학에서 지나치게 많은 학생들이 입학한 것이다. 또한 2002-2003학년도에 도입된 새로운 교육과정은 이 전 교육과정에 비해서 더 많은 자원이 투입되어야 했다. 이러한 상황에서 '첫 파트'를 성공적으로 이수한 학생들도 즉각적으로 '두 번째 파트'로 진학하지 못하는 문제가 생겼다.

In 2005, the Medical University of Graz faced an unfortunate state of affairs. Because of the open admission policy of previous years, there was an inordinate number of students enrolled in the diploma of human medicine program. Further, the new curriculum implemented in 2002–2003 required significantly more resources than the previous program. Under these circumstances, students who had successfully completed the first part of study could not immediately proceed with the second part because of a lack of resources.

이러한 상황을 해결하기 위해서, 의과대학에서는 두 가지 당시의 법적 상황을 활용하여서 새롭게 입학하는 학생의 숫자를 조절하였다. 이에 따라 2005-2006학년도에는 107명의 학생만이 새롭게 입학하였고, 그 다음 해에는 154명, 그 다음 해에는 282명으로 서서히 그 수가 증가하였다. 이러한 방식으로 Graz의과대학은 성공적으로 학생이 누적되는 문제를 해결하였다. 2008-2009학년도 이후에는 약 350명의 학생이 입학하고 있으며, 이것이 거의 상한선에 해당한다. 

To resolve this situation, the university used the new legal situation to manage the numbers of new students entering the university very efficiently. Thus, in academic year 2005–2006, only 107 new students were admitted. In the two following years, the numbers were raised incrementally (154 in 2006–2007, and 282 in 2007–2008). By this measure, we successfully eliminated the backlog of students waiting to continue their studies. Since 2008–2009, 340 to 350 students have been admitted per year, representing the upper limit of capacity. This upper limit was consensually defined with the Federal Ministry of Science and Research on the basis of previous experience.

입학 과정을 개선하기 위해서 두 가지 과정이 진행되었는데, 첫 번째로 2005-2006학년도에 1000명이 넘는 모든 지원자를 모두 임시합격시켜서 첫 학기를 이수하게 하였으며, 이 때애는 거의 인터넷을 활용한 원거리학습을 사용하였다. 첫 학기의 세 개 모듈은 모두 전자문서형태로 변환되었고, 'Graz의과대학가상캠퍼스'를 통해서만 제공되었다. 이는 종합적, 웹기반 학습 플랫폼으로 Graz의과대학에서 이전에 개발된 것이다. 2006년 1월에 임시 합격한 모든 지원자는 2일간의 선발 절차를 통과해야 하는데, 제1일에는 세 모듈에 대한 다지선다형 필기시험을 치르며, 제2일이에는 추가적은 다지선다형 시험을 통해서 생물, 화학, 물리, 수학에 대한 고등학교 수준의 지식을 평가한다. 최종 합격은 성적순으로 107명을 선발하며, 이 학생들이 최종입학하여 향후 의과대학 수업을 받게 된다. 다른 모든 학생들은 탈락된다.

Two different procedures were applied in our efforts to reform the admission process. First, in academic year 2005–2006, all applicants (more than 1,000) were preliminarily accepted for an initial semester, which entailed exclusively distance learning via the Internet. The contents of the three modules of the first study semester were transformed into electronic documents and were offered to students online by means of the Virtual Medical Campus Graz. This is a comprehensive, Web-based learning platform which had been developed previously at the Medical University of Graz 4–6 to support teaching and learning. In January 2006, all preliminarily accepted students had to pass a two-day selection procedure. On day 1, there was a written assessment in multiple-choice (MC) format based on the students' knowledge of the three modules. On day 2, the students took an additional MC test further assessing their knowledge of biology, chemistry, physics, and mathematics on the secondary school level. The available admission openings were awarded to the 107 applicants ranking highest after both assessments. These applicants then were fully admitted to further study. All other applicants were excluded from continuing their study.

두 번째 단계는 2006-2007학년도에 도입된 것으로서, 지금까지도 계속되고 있는데, Graz의과대학은 지원자의 수행능력을 기반으로 한 선발 과정을 치른다. 이 시험은 앞에서 제2일에 시행한 시험을 기반으로 만들어졌으며, 주로 고등학교 수준의 생물, 화학, 물리, 수학 시험을 보고, 과학교과에 대한 지원자의 이해능력을 평가한다. 자연과학 부분에 초점을 둔 이러한 시험을 도입한 주 근거는 오스트리아 고등학교 교육과정이 워낙 다양해서 의과대학에 입학한 많은 학생이 고전한다는 오래된 관찰 결과에 기반한 것이다. 

The second process was implemented for academic year 2006–2007, and it continues today. The Medical University of Graz employs a selection procedure based on an applicant's performance on a required MC test prior to admission. This test was built on the basis of the test used on day 2 of the previous admission test. It is based mainly on secondary-school-level knowledge of biology, chemistry, physics, and mathematics and further includes assessment of the applicant's comprehension of scientific texts. A major rationale for using an admission test focusing mainly on the natural sciences was the long-standing observation that, because of strong heterogeneities in Austrian secondary school education, many medical students faced massive difficulties—and hence, the largest risk to fail and to drop out of study—during the initial study semesters, which are dominated by these scientific disciplines.

경험이 풍부한 대학 교수가 시험을 출제하며, 시험은 매년 7월 치러지고 성적이 좋은 지원자만이 의과대학에 입학할 수 있다. 현재, Graz에서 사용하고 있는 입학 시험은 일부 독일 의과대학에서 사용하는 입학 과정과 유사하며, 이들 대학과 향후 더 협력할 계획을 가지고 있다.

Experienced university faculty produce the test items. The admission test takes place in July each year during the holiday season of schools and universities. Those applicants who rank best on the admission test are admitted to study. Presently, the admission test is used only at the Medical University of Graz, but there are similar admission procedures at some German medical faculties (e.g., University Medical Center Hamburg–Eppendorf), and we are considering cooperating more closely with these faculties in the future.

Studying the effects

우리가 기대하는 것은 학생들의 수학기간(6년 교육과정임에도 9년간 공부하는)의 단축, 그리고 탈락률(50%이상)이 감소하는 두 가지 이다.

In summary, starting with academic year 2005–2006, a fundamental change in Austria's admission practice for medical studies caused leaders at the Medical University of Graz to implement sweeping reforms to their own admissions practices. Not only was the threat of becoming overwhelmed by German students removed, the university was for the first time able to adjust the number of fresh medical students according to the capacities available. Two major research hypotheses—and indeed hopes—accompanied the introduction of selective admission procedures: We expected that students' overlong study times (approximately nine years instead of six years as scheduled) as well as the absurdly high study dropout rates (50% or more) would be efficiently reduced.

We addressed the first of these research questions, namely, the effect of the change in admission practice on study progress rates, in a previous analysis.7 In the present investigation, we investigate the second important question mentioned above: Is there a measurable effect on dropout rate of the change in admission practice from open admission to active selection of students? How large is the putative effect? Do demographic variables such as students' nationality, age, and sex significantly modulate the putative effect?

Method

Participants

We included in the study all new students routinely enrolled in the new diploma human medicine program during the academic years 2002–2003 to 2008–2009. We excluded from the investigation students being admitted by any other route (e.g., students with prior credits from medical studies at the Medical University of Graz or elsewhere).

총 2860명의 학생

In total, we included 2,860 students for statistical analyses. Of these, 1,971 (68.9%) were openly admitted during academic years 2002–2003 to 2004–2005; 889 (31.1%) were admitted after passing an admission procedure during years 2005–2006 to 2008–2009.

코호트별로 observation period가 다름

Data on study progress were accumulated from academic year 2002–2003 until the end of the winter semester in academic year 2009–2010 (February 28, 2010). Thus, the observation period varies among cohorts from the investigated academic years. Whereas students who were enrolled in 2002 and 2003 were observed for more than six years and thus were able to reach graduation during the observation time, the observation period for students who were enrolled in 2004 and later was shorter than the scheduled six years of the curriculum.

남성 여성, 연령. 연령은 3분위수를 이용하여 20.89세를 기준으로 이분화함. 1~3분위는 매우 숫자가 가까웠음. 그래서 나머지를 '나이든' 그룹으로 묶음.

The study included 1,230 men (43.0%) and 1,630 (57.0%) women. Age range was from 17.51 to 50.03 years (median: 19.69 years; first quartile: 18.92 years; third quartile: 20.89 years). As in our previous investigation,7 for subsequent analysis we arbitrarily dichotomized the variable “age at study entry” at the third quartile of 20.89 years. There was no other motivation for the dichotomization just at this age other than to compare younger and older participants; because the first, second, and third quartile are very close, the third was taken to ensure a reasonable number of participants in the “older” group. Finally, 2,481 of the students (86.7%) were Austrians, 226 (7.9%) were Germans, and 153 (5.4%) came from other nations.

학생을 선별할 수 없도록 데이터를 수집하였음. 

We gathered the deidentified data from information that is routinely collected about medical students' admission, dropout, and graduation dates and examination history, as required by the Austrian Federal Ministry of Science and Research. Because the data were anonymous and no data beyond those required by law were collected for this study, the Medical University of Graz's ethical approval committee did not require approval for this study.

통계

Statistical methods

탈락하는 학생에 대해서 학생이 탈락하고 말고 뿐만 아니라, 어느 단계에서 탈락하느냐도 중요함. 

Phenomena such as students prematurely dropping out of a program are intrinsically time-dependent: Besides the question of whether or not a student drops out, it also matters when in the course of study this event occurs. Proper analysis of dropout, therefore, must include the time elapsing between a defined starting event (in our analysis, this is the date of enrollment) and the terminating event under consideration (the date of dropout) as a central variable. 

ANOVA나 회귀분석 같은 방법은 적절하지 않음. 학생마다 모두 학습이 달라서 모든 학생이 탈락하거나 모든 학생이 졸업할 때까지 기다릴 수 없음. 

Application of ordinary statistical methods, such as analyses of variance or regression techniques, frequently are not suitable in investigations of this type. First, study progress of participants may vary considerably, and one might be interested in drawing sound conclusions without waiting until all participants have either dropped out or reached graduation. Under reasonable circumstances, only a fraction of participants will experience the terminating event “dropout” within a given observation time, and—at least in principle—other participants may get lost from the observation for reasons other than dropout (e.g., graduation). This latter phenomenon is called censoring. Participants experiencing the defined termination event during the observation period carry full information for statistical analysis (“they have experienced the terminating event after a well-defined time interval”). Participants who do not drop out of study during the observation period nevertheless contribute important information, at least for the time period under observation (“they have not experienced the terminating event during a well-defined time interval”) but not thereafter.

이러한 경우에 의학에서는 생존분석을 하게 됨. 입학 전형 또는 인구학적 특성에 따라서 탈락율 차이를 분석함.

In medicine, we meet situations of this type very commonly in survival studies. In these cases, the starting point very frequently is the date of diagnosis of, for example, a malignant tumor, and the terminating event might be the date of detection of tumor recurrence or metastasis or even death. Consequently, we analyzed the effects of open admission versus active admission procedure as well as of some selected demographic variables on dropout rates by statistical methods from the field of survival analysis.8

Here, we distinguish between nonparametric, semiparametric, and parametric methods. The product-limit approach by Kaplan and Meier 9 does not make any assumption concerning the underlying hazard function (“baseline hazard”) for the terminating event under scrutiny but estimates the cumulative probabilities of “survival” (for our purpose, this corresponds to “retention in study”) merely from the empirical data at hand. Thus, it is a nonparametric method. The proportional hazards method by Cox 10 also does not make any assumption about the baseline hazard; the effect of covariates, however, is modeled by a parameterized analytic expression. The model parameters are estimated from the data and allow, in a multivariate fashion, quantification of the relative predictive strengths of the variables included with regard to the terminating event. The Cox method is thus a semiempiric one. Finally, there are a host of parametric models which provide explicit mathematical models for the baseline hazard as well as covariate effects. These models assume one of several possible distribution models for the baseline hazard (e.g., exponential distribution, Weibull distribution, Gompertz distribution, and others) with adjustable parameters. If appropriate, such models allow the estimation of cumulative probabilities as a function of time by means of an explicit analytic expression.

We used the nonparametric product limit technique by Kaplan and Meier to compute the cumulative probabilities for retention in the course of study for student categories defined on the basis of several variables: mode of admission (open admission versus selection), sex, age, and nationality. Such cumulative probabilities are usually represented graphically by typical step functions decreasing from 1.0 to smaller values, as observation time progresses. We tested differences of cumulative retention probabilities among different categories by the generalized likelihood ratio method (Breslow [chi]2 statistic).11 To visualize the time-dependent risk of experiencing dropout for students in defined categories, we computed smoothed hazard functions for dropout according to Muller and Wang.12 These smoothed hazard functions give the instantaneous probabilities that a participant will experience a terminating event at time “t.” Roughly, they represent the negative first derivative with respect to time of the cumulative retention probabilities. We employed the semiparametric proportional hazards model by Cox in order to study the combined effects of potential predictor variables in a multivariate manner and to identify the relative strength of each individual predictor variable in the context of all other variables.

All statistical evaluations, including basic statistics for comparison of mean values and frequencies among different groups of students, were done using commercially available software (Stata Statistical Software: Release 11; StataCorp, 2009, College Station, Texas).

Results

Cumulative probability of dropout was significantly reduced in students selected by active admission procedure versus those admitted openly (P < .0001). Relative hazard ratio of selected versus openly admitted students was only 0.145 (95% CI, 0.106–0.198). 

Among openly admitted students, but not for selected ones, the cumulative probabilities for dropout were higher for females (P < .0001) and for older students (P < .0001). Generally, dropout hazard is highest during the second year of study.

Conclusions

The introduction of admission testing significantly decreased the cumulative probability for dropout. In openly admitted students a significantly higher risk for dropout was found in female students and in older students, whereas no such effects can be detected after admission testing. Future research should focus on the sex dependence, with the aim of improving success rates among female applicants on the admission tests

Dropout rates in medical students at one school before and after the installation of admission tests in Austria.

An analysis of the German university admissions system

Alexander Westkamp

독일 법에 따르면 Arbitur (secondary school을 성공적으로 마침)을 획득한 학생이라면 누구나, 어떤 학과든, 어떤 공립대학에서 수학할 자격이 주어진다. 

According to German legislation, every student who obtains the Abitur (i.e., successfully finishes secondary school) or some equivalent qualification is entitled to study any subject at any public university. Given capacity constraints at educational institutions and the ensuing need to reject some applicants, this principle has long been reinterpreted as meaning that everyone should have a chance of being admitted into the program of his or her choice. In order to implement this requirement, places in those fields of study that are most prone to overdemand have been allocated by a centralized nationwide assignment procedure for over 25 years. 

In the first part of this paper, I analyze the most recent version of this procedure that is currently used to allocate places for medicine and three specialities (dentistry, pharmacy, and veterinary medicine). In the winter term 2010/2011, more than 56,000 students applied for one of the less than 13,000 places available in these four subjects, meaning that ultimately three in four applicants had to be rejected. What sets this part of my study apart from previous investigations of real-life centralized clearinghouses is the sequential nature of the German admissions procedure: In the first step, the well-known Boston mechanism is used to allocate up to 40 % of the total capacity of each university among special applicant groups, consisting of applicants who have either obtained excellent school grades or have had to wait a long time since finishing school. 

About one month later, all remaining places—this includes in particular all places that could have been but were not allocated to special student groups—are assigned among remaining applicants according to criteria chosen by the universities using the college (university) proposing deferred acceptance algorithm (CDA). Applicants belonging to special student groups, who were not assigned one of the seats initially reserved for them, have another chance of obtaining a seat in this part of the procedure. 

Westkamp, A. (2013). An analysis of the German university admissions system.Economic Theory, 53(3), 561-589.

Abstract This paper analyzes the sequential admissions procedure for medical subjects at public universities in Germany. Complete information equilibrium outcomes are shown to be characterized by a stability condition that is adapted to the institutional constraints of the German system. I introduce matching problems with complex constraints and the notion of procedural stability. Two simple assumptions guarantee existence of a student optimal procedurally stable matching mechanism that is strategyproof for students. In the context of the German admissions problem, this mechanism weakly Pareto dominates all equilibrium outcomes of the currently employed procedure. Applications to school choice with affirmative action are also discussed.

Keywords University admissions · Matching · Stability · Strategyproofness · Complex constraints

Undergraduate medical education in Germany

Jean-François Chenot1

1 Department of General Practice, University of Göttingen, Germany

Background

독일의 첫 의학 강의는 1388년 하이델버그에서 있었다. 가장 최근에 설립된 medical faculty 는 Witten-Herdecke 에 1992년 설립되었다. 독일의 의학교육은 한 때에는 미국 의학교육의 롤모델로 일컬어지기도 했다. 그러나 최근 독일의 의학교육은 미국, 캐나다, 영국이나 네덜란드와 같은 다른 유럽국가들이 어떻게 하는지를 살펴보고 있다.

In Germany, lectures in medicine were first given in 1388 in Heidelberg. The latest medical faculty was founded in Witten-Herdecke in 1992. Medical education in this country was once praised as a role model e.g. for American medical education by Abraham Flexner [1]. Nowadays, however, the German medical faculties are looking towards the United States [2], Canada, and other European countries such as the United Kingdom and the Netherlands for good examples to follow.

독일에는 약 8만명의 의과대학생이 있고, 36개의 의과대학(medical faculties)가 있다. 매년 1만명의 새로운 학생들의 의학의 길로 들어서며, 약 6000명의 학생이 매년 졸업한다. 의과대학의 지역별 분포는 인구밀도보다는 역사적 발전배경에 따른 것이다.

Germany has about 80,000 medical students studying in 36 medical faculties (Table 1 (Tab. 1), list with URLs see Attachment 1) [3]. Each year 10,000 new students start medical education and about 6000 students graduate every year. Geographic distribution of medical faculties in Germany reflects historic developments rather than population density (Figure 1 (Fig. 1)).

약 180,000유로(한화 약 2억5천만원)정도가 한 명의 의과대학생을 길러내는데 들어가며, 이는 영국의 260,000유로와 비교되곤 한다. 그러나 한 의과대학을 제외하고는 모두 주립대학이며, 최근까지 학부의학교육은 무상으로 제공되었다. 최근에서야 일부 주에서 학기당 500유로 정도의 등록금을 학생들에게 부담시키고 있으며, 미국에 비하면 매우 낮은 편이다. 학자금 대출도 가능하다.

It is estimated that 180,000 Euros are required to cover the cost of teaching for each graduating medical student in Germany [3]. This compares to 260,000 Euros in the United Kingdom [4]. All but one medical faculty (Witten-Herdecke) are state universities, and until recently higher (undergraduate) education was free – now a few states charge up to 500,- € tuition per semester which is low in comparison to fees required for example in the United States [5]. Grants and student loans are available [6].

이러한 배경을 놓고 볼 때, 이 논문의 목적은 "Regulation of the Licensing of Doctors"가 새롭게 도입됨에 따라 해외 독자들에게 독일 학부 의학교육의 구조와 교육과정, 조직에 대해 설명하고자 하는 것이다. 

Given this background, the aim of this article is to provide international readers with an overview of the organisation, structure and curriculum of undergraduate medical education in Germany following the introduction of the new "Regulation of the Licensing of Doctors". This narrative review is based on data available from official organisations, relevant German medical journals generally not listed in Medline or EMBASE, and on personal experience. It is therefore likely to serve as a reference for reports of research in medical education in Germany and could also help international medical staff seeking to assess medical students taught in Germany who are applying for elective clerkships abroad.

Structure and curriculum of medical education

The new regulation of the licensing of doctors

독일 의학교육은 2003년 도입된 Regulation of the Licensing of Doctors의 이후에 국제 학술지에 소개된 바가 없다. 이 개혁은 독일의 정부기관, 비정부기관 등에서 독일의 의학교육이 EU의 요구조건을 만족시키지 못하고 있다는 주장이 제기됨에 따라서 도입되었다. 독일에서 의학교육에 대한 관심은 네덜란드나 영국에 비해서는 낮은 편이지만 새로운 AppOA가 도입된 이후에 모멘텀을 얻고 있으며 교육과정에도 상당한 변화가 생겼다. 주요 변화는 다음과 같다.

German Medical Education has not been described in international journals since the new "Regulation of the Licensing of Doctors" [Approbationsordnung für Ärzte (AppOÄ)], which came into effect in 2003 [7], [8], [9]. This structural reform became necessary when reports from governmental and non-governmental institutions concluded that medical education in Germany did not meet actual requirements in medical care or stipulations from the European Union [10], [11]. While interest in medical education in Germany was relatively low compared to e.g. The Netherlands or the United Kingdom, it has now gained momentum with the new AppOÄ, which required substantial changes in the curriculum. The main changes are [8]:

• Incorporation of the changed requirements in medical care
• Linkage of theoretical and clinical instruction
• Extension of interdisciplinary and topic-related instruction
• Improvement of bedside training, reduction of lectures
• Reform of examinations
• Strengthening of General Practice
• Evaluation of teaching
• Improving pain management and palliative care

의과대학에 중요한 문제는 아니었을지 몰라도, 의과대학생들에게 있어서 가장 와닿는 변화는, 완전면허(full license)를 받기 위해 필요했던 18개월간의 인턴십(AiP)가 폐지된 것이다. 이 기간의 임금은 상당히 낮은 편이었다.

Although of limited importance to medical faculties, for graduating medical students the most tangible change represented the abolishment of the lowly paid 18-month internship [Arzt im Praktikum (AiP)] before obtaining the full license to practise medicine [12].

이 다음부터는 의과대학 교육과정에 대해 다루고자 한다.

In the following description of the medical curriculum and in the discussion, the main goals of the new AppOÄ will be referred to.

Admission criteria for medical students

매우 소수의 예외를 제외하고 독일고등교육적성인증(General Certificate of Aptitude for Higher Education, Abitur)은 대학의 고등교육을 받기 위해서 반드시 필요하다. 12~13년간 학교를 다녀야 하며, 약 39%의 학생이 Abitur를 획득한다. Abitur는 미국의 '고등학교 졸업장'에 해당하는 것은 아니며, 그보다는 US colleges의 학위와 비슷한 것이다. EU내에서의 Secondary school diploma는 상호 인정을 받을 수 있으나 EU 외 지역에서 diploma를 받은 경우에는 이것이 서로 동등한 것임을 증명하는 인증을 획득해야 한다. 일부 국가에서 주되게 활용되고 있는 의학에 있어서의 undergraduate education(prepatory class, 우리나라의 의예과 개념인 듯)은 독일에서는 존재하지 않으며, 따라서 엄밀히 말하면 undergraduate 또는 graduate education이라는 개념은 옳지 않다.

With few exceptions, the General Certificate of Aptitude for Higher Education [Abitur] is a prerequisite for admission to higher education in a university. It usually requires 12 or 13 years of schooling. Roughly 39% of all school children will obtain the Abitur [13]. The Abitur cannot be compared to a high school diploma in the United States; it is closer to the associate degree of US colleges. Secondary school diplomas obtained inside the European Union are mutually recognised; however students with diplomas obtained outside the European Union have to apply for a certificate of equivalence. Undergraduate education e.g. preparatory classes for medical school, prevalent in some countries, do not exist in Germany. Therefore, the term undergraduate or graduate education does not apply in the strict sense.

독일에서 의과대학 신입생의 평균 연령은 21.4세이며, 여기에는 몇 가지 이유가 있는데 독일 남성들에게는 9개월간의 군복무 의무가 부과된다.(양심적 병역거부자(conscientious objectors)들은 대체민간봉사(alternative civilian service)한다.) 다른 분야에서의 professional training을 받는 경우 또는 waiting time으로 인한 이유도 있다. 공식적 규제는 없으나 40세가 의과대학 입학의 상한선으로 간주되고 있으며, 다른 많은 국가와 마찬가지로 의과대학의 여학생은 빠르게 증가하여 이제는 남학생보다 그 수가 많아졌다. 

In Germany, the average age of medical students is 21.4 years when they start medical school [14]. There are several reasons for this. Germany still has mandatory service of nine months for men either in the military or an alternative civilian service [Zivildienst] for conscientious objectors. Additionally due to waiting time or professional training in other areas, a significant proportion of students are older. Although there is no formal regulation, an age of 40 years is considered the upper limit for entering medical school. Similar to many other countries, the number of women studying medicine has increased steadily and is now exceeding the proportion of male students [15]. This however is not yet reflected in higher academic ranks.

Selection of medical students

의과대학에 지원하는 지원자의 수는 정원보다 훨씬 많아 입학 정원이 제한되어 있다. 평균적으로 4~5:1정도의 경쟁률이 되나, 대학마다 차이가 크다. 독일에서 의과대학 지원과 선발은 ZVS라는 중앙 국가 기관에 의해서 운영된다. 입학 기준으로는 Abitur grade(미국의 GPA에 해당)와 대기시간(waiting time)이 있다. Abitur는 교육과정을 성공적으로 마칠 것인가에 대한 가장 좋은 예측인자이다. 각 학생은 한 번에 6개까지 의과대학에 1순위부터 6순위까지 지원을 할 수 있으며, 대부분의 의과대학 학생은 이러한 절차를 거쳐서 입학하게 되나, 일부 해외 학생이나 군(military)를 위한 정원이 있다.

The number of applicants to medical schools largely exceeds the number of available places; therefore admission is subject to restrictions [numerus clausus]. On average four to five prospective students apply for each place, however there are large differences between the faculties. In Germany, application to medical schools is administered by a federal organisation, the Central Office for the Allocation of Places in Higher Education [Zentralstelle für die Vergabe von Studienplätzen (ZVS)] [16]. Criteria for admission are the overall Abitur grade, which is roughly comparable to the American Grade Point Average (GPA), and waiting time. The Abitur is considered the best predictor for successful completion of the curriculum [17]. Each student can rank and apply to 6 medical schools at once. The majority of medical students (80%) used to be admitted by this process and there is a quota for foreign medical students and the military.

의과대학에 의해서 자체적으로 선발되는 학생의 비율은 60%까지 증가하였다.(?). 대부분의 학생은 의과대학에 지원동기를 제출하는데, 의과대학에서는 이 지원서를 살펴본 후에 일부 학생을 대상으로 면접을 한다. 그러나 종종 이 단계는 시간이 굉장히 많이 소모되며 지원자의 수가 너무 많은 때도 있다. 따라서 의과대학에서는 교수들에게 이 과정에 참여하라고 독려하기가 쉽지 않다. 또한 미래 의사가 될 학생을 선발하는 criteria에 대한 합의가 없는 경우도 있다. 이러한 상황에서 TMS라는 국가적 의과대학입학시험은 1997년 폐지되었으나 일부 의과대학에서 다시 도입되기도 하였다. TMS는 미국의 MCAT에 비유될 수 있으며, TMS가 의무사항은 아니지만 선발 단계에서 면접대상자로 뽑힐 가능성을 높여주는 면은 있다.

The proportion of students who are selected by the medical schools themselves is supposed to increase to 60%. Usually students apply with a letter of motivation to medical schools. After screening the applications a few are invited for interview [18]. However the process is time consuming and sometimes the number of applicants is overwhelming. Therefore faculties find it difficult to motivate faculty members to participate in the selection process. There is also often no consensus on the criteria that should be used to select future doctors. Given this situation, the nationwide medical admission test [Test für Medizinische Studiengänge (TMS)], which had been abandoned in 1997, has been reintroduced by some faculties [19]. The TMS is comparable to the American Medical college admission test (MCAT) [20]. The TMS is not mandatory but allows students to improve their score and their chance of being selected to come for an interview.

Structure of the curriculum

독일에서 의학교육은 다른 많은 국가가 '연' 단위로 되어있는 것과 달리 '학기'단위 또는 일부 경우 '3분기(trimester)' 단위로 구조화되어있다. 교육과정을 마칠 때 까지는 총 6년(12학기)+3달이 걸리며 평균적으로는 6.8년정도 학교를 다닌다. 교육과정은 크게 세 섹션으로 나뉜다.

In Germany, medical education is structured, not in years like many other countries, but in semesters or in a few instances, trimesters (Hamburg, Hannover). It takes six years (12 semesters) and three months to complete the curriculum, however on average, students require 6.8 years [3]. The curriculum is divided into three sections (Table 2 (Tab. 2)):

• Basic science (2 years)
• Clinical science (3 years)
• Clinical year (1 year)

대다수의 학생은 이 단계를 따르게 되며, 일부 의과대학은 실험적 교육과정을 운영하기도 한다.

The majority of medical students follow this track. Some medical faculties have chosen to offer an experimental curriculum [Modellstudiengang] which offers an alternative process to becoming a doctor (Table 1 (Tab. 1)) [21].

Basic science [Vorklinik] 

기초의학 과정의 내용과 구조는 거의 변화가 없으며, 주 과목은 해부학, 생리학, 생화학, 사회과학이다. 대부분 Pass또는 Fail로 평가한다. 기초의학과 임상의학 사이의 간극이 비판을 받고 있는데, 졸업생들은 이 기초과학 내용이 임상에서 거의 쓸모가 없다고 평가하고 있다. 따라서 기초과학을 임상적 맥락에서 교육하기 위한 노력이 지속적으로 이뤄지고 있으며, 3달간의 nursing stage가 기초의학 부분에서 의무적으로 운영되고 있다. 그러나 추가적인 준비과정을 운영하고 있는 사립 기관(private institutions)이 점차 증가하고 있으며, 이는 의사국가시험을 합격하기에 충분한 교육이 이뤄지지 못한다는 것을 의미한다.

The content and structure of the basic science section (also preclinical science) has remained largely unchanged. The main topics are anatomy, physiology, biochemistry and social sciences (Table 2 (Tab. 2)). Courses are usually not graded beyond pass or fail. The distinction between clinical and basic science has been criticised and graduate students have rated large parts of the curriculum as clinically irrelevant [22]. Therefore there are increased efforts to place basic science in a clinical context [23], [24]. A three month nursing stage is a mandatory part of the basic science section to ensure first patient contact. However private institutions are increasingly offering additional preparatory classes, which might indicate the failure of the faculties to provide the necessary skills and knowledge to pass the state medical licensing examinations.

Clinical science [Klinik] 

임상과학은 21개의 전공과목을 포함하며, 예전에는 각각의 과목을 개별적으로 가르쳤다. 그러나 이제는 여러 과목을 학제간교육모듈(interdisciplinary teaching modules)로 교육하고 있어서 "head module"에서는 귀, 코, 목, 안과 등을 같이 다룬다. 추가적으로 12개의 학제간교육모듈이 도입되었으며, 대체로 첫 해에는 임상과학의 도입부분으로 병력청취와 신체검진의 기본 기술을 익힌다. 또한 일반 병리학, 일반 미생물학, 일반 약리학, 실험의학 등을 배운다. 전통적으로 임상과학 교육과정은 환자 노출이 별로 없고 강의와 세미나로 진행되었는데, 임상경험을 강화시키기 위해서 의무적 임상실습이 내과, 일반외과, 소아과, 산부인과, 일반과(General Practice) 과목에 도입되었다. 정신과학이 대부분의 국가에서 핵심 과목으로 다뤄지는 것과 달리 독일에서는 의무가 아니다. 임상술기실습(Clinical skill lab)이 여러 대학에서 도입되었으며, 학생은 한달짜리 elective clerkship을 선택할 수 있다. 한 개의 clerkship은 외래에서 진행되어야 한다. 

The clinical science section covers 21 medical specialties as listed in Table 2 (Tab. 2). Previously each subject was taught separately. Now subjects are often taught in interdisciplinary teaching modules e.g. a “head module” combining Ear, Nose & Throat Medicine with Ophthalmology [25]. Additionally 12 new interdisciplinary teaching modules [Querschnittsbereiche] have been introduced (Table 3 (Tab. 3)). Usually the first year is dedicated to the introduction of the clinical sciences with basic skill training in history taking and physical examination, general pathology, general microbiology, general pharmacology and laboratory medicine. Traditionally the clinical science section consisted mainly of lectures and seminars with limited patient exposure. To strengthen clinical experience, mandatory clerkships [Blockpraktikum] have been introduced in Internal Medicine, General Surgery, Paediatrics, Obstetrics & Gynaecology and General Practice. It is notable that a clerkship in Psychiatry, which is considered a core subject in many countries, is not mandatory. Clinical skills labs have been newly established in most faculties [26]. Additionally students have to complete four one-month elective clerkships, traditionally called Famulatur [famulus latin: servant]. One clerkship has to be completed in the ambulatory setting. It is very popular to perform at least one elective outside Germany with a preference for English speaking countries.

Clinical year [Praktisches Jahr: PJ] 

마지막 학년은 세 개의 full-time clinical rotation으로 구성되어 있으며 각각은 4달씩 진행된다. 내과와 외과 rotation은 의무적으로 들어가야 하며, 한 개는 임상과들 중 자유롭게 고를 수 있다. 예전에는 마지막 학년은 병원을 중심으로 훈련을 받아야 했지만 새로운 AppOA에서는 외래 기반 세팅에서도 실습이 가능해졌다.

The final year is divided into three full-time clinical rotations, each lasting about 4 months (Table 2 (Tab. 2)). Rotations in Internal Medicine and Surgery are mandatory and one rotation can be freely chosen from all the clinical specialties. Previously, the final year had been restricted to hospital based training sites. The new AppOÄ made it possible for the first time to complete a clinical rotation in an ambulatory setting, e.g. in General Practice [27].

마지막 학년 내에서도 학생은 점차 더 많은 책임을 지게 되는데, 이는 서브인턴십과 비슷한 것이다. 법적인 문제들이 학생들이 직접 자신이 해볼 수 있는 임상 경험을 쌓는데 제한이 되고 있다. 혈액 채취나 IV line을 잡는 것은 대부분의 국가에서 AN에 의해서 이뤄지지만, 독일에서는 이런 일 때문에 최종학년 학생(PJler)들이 바쁘다. 일반적으로 학생들이 임상현장에서 배우는 것을 당연하게 받아들이지만, 감독과 지시의 수준은 무척 다르다. 

Students usually assume more responsibilities gradually during the final year, comparable to a sub-internship. Legal 

issues regarding delegation and liability limit students’ opportunity to gain hands on experience [28]. Hospitals often rely on the work accomplished by the final year students [PJler]. Unfortunately, taking blood samples and inserting intravenous lines, which is done by auxiliary nurses in most other countries, keeps PJ students busy [29]. It is generally taken for granted that students learn skills on the job, but the degree of supervision and instruction varies widely [30]. Multiple projects to improve the quality of teaching in the clinical year have been presented and only a few can be cited here [31], [32].

스위스에서 독일어를 사용하는 지역에서는 최종학년 학생들에게 일정부분의 보상을 지급하고, 이렇게 보상을 지급하는 것에 대한 논쟁이 있다. 의사 부족이 점차 심해지면서 일부 교육병원(teaching hospital)에서는 학생들을 졸업 후 수련과정에 유지시키기 위해 특별히 노력을 기울이고 있다.

As the German-speaking region of Switzerland offers a basic remuneration to final year students, there is a debate as to whether students should be paid. With the increasing shortage of physicians, some teaching hospitals are known to make special efforts to retain some students for postgraduate training.

Examinations

새로운 AppOA가 도입되기 전까지는 의과대학생의 학업성취도는 pass/fail로 평가되었고, 면허시험만이 점수를 주게 되어 있었다. 대학의 입장에서 새로운 regulation이 불러온 가장 큰 변화는 (1)각각의 교과목과 임상실습에 대한 grade를 매겨야 하는 것, (2)면허시험을 3단계에서 2단계로 축소시키는 것이었다. Grade는 1(excellent)에서 5(fail)까지 순위로 매겨진다.

Until the new AppOÄ, the achievements of medical students in courses and clerkships were evaluated simply with a pass or fail. Only state licensing examinations were graded. From the faculties perspective the most radical changes with the new regulations for medical education were 1. the requirement to grade each course and clerkship and 2. the reduction of the number of licensing examinations from three to two. Grades are given on an ordinal scale ranging from 1 (excellent) to 5 (fail).

대학의 책임을 강화하는 것이 가져온 효과는 다양한데, 기존의 대학은 시험에 최소한의 노력만을 기울였고, 여기에 노력을 쏟는 것은 주정부(state authorities)에 의해서 운영되는 면허시험이었다. 면허시험을 치르기 위한 인증(certificate)를 받기 위해서 학생들은 공식적 평가과정을 밟지 않거나 매우 조금만 밟아도 되었고, 대부분 출석만 잘 하면 인증을 받을 수 있었다. 해부학과 같은 소수의 과목에서만 시간을 들여서 구두시험을 치렀다. 과거에는 최종 면허시험이 유일한 summative grade였다.

Strengthening the responsibility of faculties had mixed effects. Previously faculties invested only a minimal effort with respect to examinations. This was left to the centrally organised state licensing examination administered by state authorities [Landesprüfungsamt]. Students received certificates [Scheine] with little or no formal assessment in each of the subjects required in order to register for the licensing examinations. Most often physical attendance during the course was sufficient to obtain the course certificate. Only a few subjects such as anatomy required time consuming oral examinations. Previously, on the final licensing examination certificate only one summative grade of the written multiple choice exams and the final oral examination appeared on the diploma.

이제는 각각의 과목이 반드시 grade로 평가되고 최종 학위에 표기되어야 한다. 한편으로 이러한 정책은 OSCE와 같은 평가법의 도입을 유도했고, 다른 한 편으로 이러한 시험을 도입하는 것이 작은 교실에서는 상당한 부담을 가져왔다. 예를 들어 psychosocial science 학과 등에서는 수용능력을 초과하는 구두시험은 치를 수가 없게 되었다.

Now each subject must be graded and appears on the final diploma. On the one hand this has led to the introduction of modern assessment tools to evaluate practical skills like the objective structured clinical examination (OSCE) in several faculties [33]. On the other hand time and staff consuming examinations turned out to be a burden especially for smaller departments. For example psychosocial sciences in the preclinical section had to stop administering oral exams exceeding their staff capacities.

새로운 면허시험은 다지선다형 필기시험과 구두시험으로 구성되어 있다. MCQ의 개발은 IMPP가 주관한다. 대학별로 나름의 교육과정이 있으나 IMMP는 필기시험에서 다뤄지는 주제의 카탈로그를 가지고 있다.

The new licensing examination consists of a written test with multiple choice questions (MCQs) and an (unstructured) oral examination. The administration and development of MCQs continues to be organised by the Institute for medical and pharmaceutical examination questions [Institut für Medizinische und Pharmazeutische Prüfungsfragen (IMPP)] [34]. Although each medical faculty has its own curriculum, the IMMP has a catalogue of topics covered by the written exams [Gegenstandskatalog].

면허시험의 앞 파트는 예전에 Physikum이라 불리던 것으로서 임상실습을 하기 위해서 이 시험을 반드시 통과해야 한다. 약 20%정도의 학생이 탈락하며, 두 차례까지 볼 수 있다. 5%학생이 결국 탈락하게 되며, USMLE step1에 해당하는 시험은 아니다.

The first part of the medical licensing examination [Erster Abschnitt der Ärztlichen Prüfung], traditionally called “Physikum”, is the first hurdle students have to take. In order to proceed to the clinical section, this examination must be passed. The average initial failure rate is roughly 20%. The examination can be repeated twice; about 5% of all students never pass. This exam is not equivalent to the USMLE step 1 (United States Medical Licensing Examination).

면허시험의 새로운 두 번째 파트는 Hammerexamen이라 불리며, 괴물시험(monster exam)이라고 번역할 수 있다. 이는 기존에 별개였던 세 개의 시험을 대체하는 시험으로 임상과학의 전체적인 스펙트럼을 모두 포괄한다. 필기시험과 구두+실기시험이 합해진 시험으로 구성되는데, 이 시험의 별명(괴물시험)이 말해주는 것처럼, 필기시험의 탈락율이 2%에서 9%로 치솟았다. 구두+실기시험을 탈락하는 학생은 적으며, 이는 이 시험에 대한 비판중 한 가지이다. 

The new second part of the medical licensing examination [Zweiter Abschnitt der Ärztlichen Prüfung] of the clinical year has colloquially been termed “Hammerexamen” which can roughly be translated as “monster exam”. It has replaced three previously separate examinations and covers the entire spectrum of the clinical sciences. It consists of a written exam and a combined oral and practical exam. This exam lives up to its nickname since the previously low failure rate associated with the written part rocketed from 2% to 9%. Only a few students fail the oral and practical examination, which is only one of several reasons that this exam format has been criticised [35]. 

학생들이 '괴물 시험'에 대한 준비에만 초점을 맞추다가 임상실습과 학습에는 소홀해진다는 비판도 있다. IMPP가 필기고사 문항을 드문 질환 위주로 만들면서 더 통합적이고 임상적으로 중요한 것을 소홀히한다는 의견도 있다. 비록 새롭게 도입된 사례중심 문항형식이 MCQ 문항을 많이 발전시켰다고 보기도 하지만, 의학적으로 특이한 사례를 암기하고 별로 중요하지 않은 사실들을 아는 것이 여전히 중요한 부분으로 남아있다.

It is also felt that final year students are less well prepared than previous generations who took the last written examination before entering the clinical year. It is suspected that students focus on preparing for the “monster exam” and are distracted from clinical practical work and learning [36]. It had been hoped that the tendency of the IMPP to create multiple choice questions around rare syndromes would be abandoned in favour of more interdisciplinary and clinically relevant topics. Although the new case-based format still consisting of multiple choice questions is considered a significant improvement, remembering medical oddities and irrelevant facts still remains important [37].

Ranking of medical faculties

독일에서 의과대학의 순위는 상대적으로 새로운 것으로, The German Academic Exchange Service는 연구/시설/학생평가 등등을 기준으로 평가를 하였다. 면허시험에서의 학생의 수행능력을 기반으로 한 평가도 가능하다. 

Ranking of faculties is rather new in Germany and, as elsewhere, dependent on the selection criteria. The German Academic Exchange Service has ranked medical faculties in various topics including research, infrastructure and student evaluation [38]. Ranking based on students’ performance in state licensing examination is also available [39]. Adjustment for differences in allocation of resources per capita or the proportion of foreign medical students has a significant impact on ranking.

Title

최종 면허시험을 통과한 학생은 의술을 행할 수 있는 면허가 주어지나 academic title이 붙은 academic degree는 주어지지 않는다. 졸업생들은 Arzt라는 전문직 타이틀을 쓸 수 있으나, 비공식적으로 일반적으로는 "Dr."라고 불리기도 한다. 다른 나라와 마찬가지로 학위논문을 쓰는 것이 "Dr.med"를 받기 위해서 필요하다. 70%의 졸업생이 학위논문을 마무리짓는다고 나오며, 이는 이것이 진로/승진과 환자 유인에 유리하기 때문이다.

A student who passes the final licensing examinations is awarded a license to practice medicine [Approbation als Arzt], but does not receive an academic degree with an academic title [40]. Graduates are authorised to use the German professional title Arzt/Ärztin (Physician), but are generally addressed informally with the honorary title "Dr." [Doktor]. As in other countries, writing a dissertation/thesis is an option required to obtain the academic degree “Dr. med.”. It is estimated that 70% of all graduates will eventually complete a dissertation, which is perceived to be important for career promotion and to attract patients [41].

Discussion

Implementation of reforms in medical education

Excellent doctors are the result of an excellent medical education. The new "Regulation of the Licensing of Doctors (AppOÄ)" has certainly fostered important improvements in the education of medical students in Germany. The increased interest in medical education is documented by the dynamic development of the German Society for Medical Education [Gesellschaft für Medizinische Ausbildung] [42] and the introduction of the first postgraduate Master of Medical Education (MME) programme in Germany in 2005 [43]. Previously the only German-speaking MME-program was offered by the University of Bern in Switzerland.

It is uncertain if the goals of the new AppOÄ have been achieved as there are no official reports available. However, some professional organisations have conducted surveys.

Strengthening the role of General Practice in the face of an anticipated shortage of general practitioners was one of the multiple goals of the reform. Although some faculties have founded new Departments of General Practice, more than half of all faculties have no such department [44]. Similarly the stipulated strengthening of palliative care and pain management has also not yet been achieved in all faculties [45]. A national survey of teaching in Geriatrics, which had not previously been a component of the curriculum but is now covered by a mandatory interdisciplinary teaching module “Medicine of aging and the elderly”, revealed that less than half of all medical faculties provide teaching in this topic [46].

Mandatory evaluation of teaching was also among the aims of the AppOÄ. The main purpose of evaluation is quality control but also distribution of funds [47]. The last national survey on the evaluation of medical teaching in Germany was performed in 2000 before the reform [48]. Multiple evaluations of courses have been reported (selected examples [49], [50]) however there is no national standard and reporting bias is likely.

Unlike other university programmes awarding degrees to students, medical faculties in Germany are not subject to formal mandatory accreditation and reaccredidation procedures, since the final degree is a license awarded by the state. Although the German Council of Science and Humanities [Wissenschaftsrat] [51] has evaluated medical faculties, it is left to the discretion of the states as to how to ensure compliance with the stipulated requirements [52]. So far only one faculty has been on probation in 2005. It is conceivable that the states, which are responsible for funding medical faculties, have a conflict of interest given that external accreditation might reveal deficiencies due to under-funding.

Barriers to the implementation of stipulated reforms

Enacting the new AppOÄ was a pure administrative act and unfortunately was not provided with a budget to ensure its implementation [53]. Medical faculties are facing incredible difficulties to fulfil all the new requirements. The reduction in the number of lectures and rise in bedside teaching has increased the need dramatically for both clinical teachers and available patients. Although lip service is paid to the commitment for medical education, young academics are not rewarded for their efforts, and teaching, which must compete with research and patient care, is sometimes considered a lost cause [54].

At the same time, virtually all university hospitals to which medical schools are attached are in serious financial crisis, partly due to a new invoicing system and budget cuts [55]. Some of the previously state-owned university hospitals have been privatised (e.g. Giessen and Marburg) or transformed into foundations (e.g. Göttingen). This has increased the already pressing need for separate accounting of patient care financed by hospital revenues and teaching, and research covered by state grants or third-party funds. This has turned out to be extremely difficult since a significant proportion of the faculty is actively involved in both [56]. Only a few medical faculties (e.g. Kiel/Lübeck, Dresden/Leipzig) are administered completely separately from university hospitals [57]. The funding of medical education has been described in more detail elsewhere [58].

European perspective

In 1999, the Education Ministers from 29 European countries including Germany adopted the Bologna declaration [59]. The principal goals of this were to permit easily readable and comparable university degrees within Europe and to introduce a system essentially based on two main cycles, undergraduate and graduate, thus increasing mobility within Europe. In fact the mobility of medical students is already hampered at a national level by the multitude of non-compatible curricula although the Bologna declaration should also theoretically apply to medical education. However, this idea is neither encouraged by the German Medical Association nor some other medical associations [60]. The main reason to reject the implementation of the Bologna declaration for medical training is the fear of introducing a fast track “barefoot doctor”.

Conclusion

Improving and adapting education of medical students to the health needs of the population is a continuous process. The new "Regulation of the Licensing of Doctors (AppOÄ)" in Germany has stimulated multiple excellent projects to help future doctors meet these needs, but there is evidence that some of the stipulated changes have not been implemented. This review is an initial attempt to assess the compliance with the requirements of the AppOÄ and the success of the changes stipulated therein. Unfortunately it has not been possible to do justice to the educational activities in all 36 faculties, and while it is recognised that only a few selected projects have been discussed here, it is clear that mandatory external accreditation and periodic reaccreditations of medical faculties needs to be established in Germany [61].

List of abbreviations used

• AppOÄ: Approbationsordnung für Ärzte [Licensing Law for Medical Doctors]
• GPA: grade point average
• IMPP: Institut für Medizinische und Pharmazeutische Prüfungsfragen [Institute for medical and pharmaceutical examination questions]
• MCAT: Medical College Admission Test
• MCQ: multiple choice questions
• PJ: Praktisches Jahr [final year in medical school]
• TMS: Test für Medizinische Studiengänge [Test for medical education]
• USMLE: United States medical licensing examination
• ZVS: Zentralstelle für die Vergabe von Studienplätzen [Central office for the allocation of places in higher education]

Undergraduate medical education in Germany.

Germany; reform; undergraduate medical education

Blended learning approach improves teaching in a problem-based learning environment in orthopedics - a pilot study

David A Back1,2,7*, Nicole Haberstroh3, Andrea Antolic4, Kai Sostmann5, Gerhard Schmidmaier6 and Eike Hoff3,7

Discussion

BMC Med Educ. 2014 Jan 27;14:17. doi: 10.1186/1472-6920-14-17.

Blended learning approach improves teaching in a problem-based learning environment in orthopedics - a pilotstudy.

Cutting costs of multiple mini-interviews – changes in reliability and efficiency of the Hamburg medical school admission test between two applications

Johanna C Hissbach1, Susanne Sehner2, Sigrid Harendza3 and Wolfgang Hampe1*

BMC Med Educ. 2014 Mar 19;14:54. doi: 10.1186/1472-6920-14-54.

Cutting costs of multiple mini-interviews - changes in reliability and efficiency of the Hamburg medical schooladmission test between two applications.

[프리미엄] 좋은 머리만큼 '따뜻한 심장'도 지녔는가… 달라진 醫大 면접

[출처] 본 기사는 조선닷컴에서 작성된 기사 입니다

방 안엔 교수 면접관 2명이 앉아 있었다. 면접관들은 8분 동안 수험생에게 속사포 같은 질문 공세를 펼쳤다. 종료 벨 소리와 함께 수험생들은 한 칸씩 옆방으로 이동했고, 질문만 다를 뿐 똑같은 과정이 되풀이됐다. 수험생들은 이런 식으로 60분 동안 모두 6개의 면접실을 돌았다. 모든 과정은 마치 톱니바퀴가 돌아가는 듯했다. 중간에 쉬는 시간도 없었다

서울대 의대가 2012학년도부터 도입한 이 면접은 '다면(多面) 인·적성 면접(MMI·Multiple Mini Interview)'. 의사로서의 기본적인 인성과 적성을 검증하는 면접법이다. 처음엔 의학전문대학원 수시에 적용했고 이후 2013학년도 의대 수시, 2014학년도 의대 정시로 확대했다

◇의사, 인성과 적성이 중요하다

서울대 의대는 MMI 도입 취지에 대해 "의사소통 능력과 라포르(rapport·의사와 환자의 심리적 신뢰) 형성 능력이 있는 지원자를 선발하고, 공부만 잘하는 지원자는 걸러내기 위한 시도"라고 밝혔다.

의대생을 뽑을 때 인성과 적성을 중시해야 한다는 것은 의학계의 오랜 화두(話頭)다. 사정은 외국도 마찬가지다. 뉴욕타임스는 몇 년 전 '의사 지망생을 위한 새로운 인성·사회성 테스트'란 제목의 기사에서 "미국 의대 가운데 MMI를 도입하는 곳이 늘고 있다"고 전했다. 그 이유로는 ▲실력 좋은 의사들이 환자·간호사 등과 소통이 안 돼 충분히 막을 수 있었던 환자의 죽음을 막지 못하는 사례가 늘고 있으며 ▲현대 의술이 갈수록 팀플레이 위주로 전개돼 의사에게 소통 능력이 요구되고 있는 점을 꼽았다.

MMI는 지난 2001년 캐나다 맥마스터 의대가 처음 도입했으며, 현재는 캐나다 대부분 의대가 시행하고 있다. 이후 미국으로도 넘어가 뉴저지, 캘리포니아, 버지니아, 오하이오 등의 주요 주립 의대가 실시 중이다. 미국 명문 사립 의대 중엔 스탠퍼드가 2010년 도입했다.

우리나라에서는 강원대 의전원이 2008학년도 입시에서 처음 시행했고, 한림대 의대가 2011학년도 입시에 도입했다. 그 외 인제대 의대, 가천대 의대 등이 시행 중인 것으로 알려졌다. 또 최근 발표된 서울대 2015학년도 입시전형 안내에 따르면 이 대학 수의대·치대도 수시 전형에서 MMI를 실시할 계획이다.

◇학생들… "살아온 모습 드러나더라"

서울대 의대의 MMI는 총 6개의 방으로 구성됐다. 이 학교 입학 관계자는 "면접실 6개 중 1개는 학생들이 제출한 서류나 학생부 등을 확인·검토하는 방"이라며 "나머지 5개 방에서는 의대 산하의 문항개발위원회가 자체 개발한 문항으로 면접을 진행한다"고 설명했다.

서울대 의대 신입생들은 "면접에 나온 문항은 수학·과학 능력을 검증하는 것이 아니었다"고 입을 모았다. 예를 들어 '친구가 대학 입시 자기소개서에 허위·과장 내용을 기재해 제출한 사실을 알게 됐다. 어떻게 할 것인가' '친구 5명과 인도 여행을 떠나기로 했다. 경비 마련, 역할 분담 등을 어떻게 할 것인가' 등 일상적인 내용을 담은 문항이 주로 제시됐다고 했다. 방에서는 문항과 관련된 추가 질문이 쉴 틈 없이 이어졌다고 한다.

(출처 : http://blog.chosun.com/blog.log.view.screen?userId=besetohan&logId=7417996)

Attitudes towards statistics of graduate entry medical students: the role of prior learning experiences

Ailish Hannigan1,2*, Avril C Hegarty3 and Deirdre McGrath1,2

Results

Discussion

가장 확실한 예측인자는 과거에 수학과목을 얼마나 잘 했다고 생각하는지였다. 이러한 연관관계에 대해서 통계 교육자들이 좀 더 설명해줄 필요가 있다. 또한 통계학적 사고가 필요로 하는 것이 다르고, 수학과도 서로 다른 특성이 있으므로 이러한 것을 강조하여 학생들이 좀 더 부정적인 생각은 줄이고 열린 마음으로 받아들이도록 도와줄 수도 이씅ㄹ 것이다. 

The strongest predictor of most of the attitude components was how well students felt they had performed in mathematics in the past. This association of past experiences in mathematics with attitudes towards statistics needs to be addressed by statistics educators. Increasingly, statistics is viewed as a separate discipline rather than a subfield of mathematics [17]. Cobb and Moore [18] propose that ‘statistics requires a different kind of thinking, because data are not just numbers, they are numbers with a context’. Statistics did not originate in mathematics and the role of context, variability and data production in statistics differentiates statistical thinking from mathematical thinking. Statistical thinking also relies heavily on interpretation and critical judgement. There is increasing evidence that a strong background in mathematics does not necessarily translate to performance in statistics. Evans [4] demonstrated that students studying statistics in other disciplines such as sociology had more positive attitudes and correct conceptions of statistical fundamentals than mathematics students. Hannigan et al. [15] demonstrated that despite being very mathematically able and confident, a sample of prospective mathematics teachers did no better in an internationally used assessment of conceptual understanding of statistics than students from mostly non-quantitative disciplines. Highlighting the differences between mathematical thinking and statistical thinking may encourage medical students with negative experiences in mathematics in the past and poor perceptions of their ability in mathematics to ‘start afresh’ with statistics and be open to the idea that they will be able to use and understand statistics. Increasingly, statistics educators are encouraged to ground the teaching of statistics in context. Miles et al. [19] suggest that grounding the teaching of statistics in the context of medical research and typical clinical scenarios may better prepare medical students for their subsequent careers. Freeman et al. [3] demonstrated that a multidisciplinary approach to the teaching of medical statistics bringing together a statistician, clinician and educational experts to re-conceptualize the syllabus and placing greater emphasis on applying statistics and interpreting data can bring about better outcomes for students.

Attitudes towards statistics of graduate entry medical students: the role of prior learning experiences.

Interprofessional education in primary care for the elderly: a pilot study

Barth Oeseburg1*, Rudi Hilberts2, Truus A Luten3, Antoinette VM van Etten4, Joris PJ Slaets5 and Petrie F Roodbol1,2

Results

Conclusion and discussion

Despite the fact that the IPE program was developed in close cooperation with expert groups, the program did not entirely meet the expectations of the participants. The length of the program, four half day sessions, was deemed too short to adequately increase the knowledge on, for example, the interpretation of the data generated by the triage instrument. The program was also too short to address the needs of the participants regarding practical tools and evidenced based interventions to handle certain problems in the elderly. Furthermore, participants found the information on the IPE program too concise, and GPs did not inform their practice nurses sufficiently about the program’s content. Indeed, this latter point could have influenced the expectations of the participants and the subsequent success of the program [29].

그러나, 이것은 파일럿 연구이고, 파일럿 연구의 특징은 참여자들이 subject이면서 developer라는 사실이다.

However, this was a pilot study, and one characteristic of a pilot study is that participants are both subjects and developers of the intervention at the same time. The results of this pilot study and the participants’ suggestions for improvement will be used to develop an adapted interprofessional education program for GPs and practice nurses.

Findings in relation to other studies

기존 연구가 많지는 않지만, 부합하는 결과임

To our knowledge, there is a paucity of literature on interprofessional education specifically pertaining to GPs and practice nurses in primary elderly care [31]. Our results are in line with the limited research on interprofessional learning in primary care and reviews on interprofessional education [14,31,32].

Kirkpatrick모델에서 attitude와 performance가 변화하였음

A study by Pearson & Pandya [31], for example, found that primary care professionals value interprofessional education and the sharing of knowledge and expertise. In keeping with a recent review of Reeves et al. [14] on the effectiveness of interprofessional education, our pilot study shows a change in the attitudes of the participants and their performance in practice: level 1 – 2/3 Kirkpatrick’s model [27]. As mentioned above, the impact of the IPE program on the health care system itself and on patient outcomes was not measured in our pilot and could therefore not be compared with findings in other studies.

IPE프로그램이 성공하기 위해서 넘어야 할 장벽들이 있다.

The participants in this pilot study mentioned some barriers to the success of the IPE program. In the literature, other barriers are also mentioned that hinder the implementation of an interprofessional education program. These barriers include...

the social identity of professional groups,
hierarchical relations between professionals,
lack of time,
workload, and
lack of financial incentives for the education program and for interprofessional collaboration in practice. 

In addition, factors related to the implementation and change process of professionals and practices such as...

the support of senior management,
dynamic leadership,
inclusion of all staff members,
a proactive approach to prevent resistance, and
sustaining change during and after the initial implementation process are important [10,30,33-37].

이러한 문제에도 불구하고 전문직종간의 협력은 보건의료시스템에서 대단히 중요하다. IPE와 IP collaboration의 관계가 명확하지는 않지만, 이 관계를 밝히기 위한 노력은 중요하다.

However, despite these start-up problems, collaboration between professionals is crucial in today’s increasingly complex healthcare system. Although the literature indicates that the link between interprofessional education and interprofessional collaboration is not clear, working on clarifying this link is worthwhile [10,38-41]. There is a need for theory-driven development and implementation of interprofessional education programs, combined with high quality research on the effects of interprofessional education. Future research is necessary to learn more about the effects of interprofessional education on an individual level, i.e. how professionals learn in certain settings and why some are more capable than others; as well as its effects on an organisational level, i.e. how factors such as the organisation of care, financial incentives, costs, and patients outcomes influence the health care system [16,30,33,39-41].

BMC Med Educ. 2013 Dec 5;13:161. doi: 10.1186/1472-6920-13-161.

Interprofessional education in primary care for the elderly: a pilot study.

Empirical evidence for symbiotic medical education: a comparative analysis of community and tertiary-based programmes

Paul Worley,1 David Prideaux,2 Roger Strasser,3 Anne Magarey4 & Robyn March1

Med Educ. 2006 Feb;40(2):109-16.

Empirical evidence for symbiotic medical education: a comparative analysis of community and tertiary-basedprogrammes.