Medical education in the USA--adult-friendly?

In the United States of America, the Area Health Education Center (AHEC) system of training residents has allowed high-quality postgraduate education to flourish. This paper describes the evolution of the AHECs in the context of medical education over the past 50 years. The arrangements for programme administration and design, resident assessment and appraisal, training of trainers in educational methods, and the accreditation of training programmes are discussed. The fast-evolving UK postgraduate education scene can learn some useful lessons from the US system.     

基于混合研究方法对比两个全科培训基地全科住院医师对培训的态度和看法

背景　中国正在完善分级诊疗和家庭医生制度,全科医生人才培养是实现这一制度的核心因素,目前我国全科医生缺口40万,全科住院医师规范化培训是培养高质量全科医生的主要途径。目的　通过混合研究方法广而深地了解来自两个城市的两个医院全科住院医师对其接受的全科规范化培训看法的异同,探讨不同规范化培训模式下可能带来的益处。方法　应用混合研究方法进行横断面研究。于2019年4月,采用整群抽样法抽取北京大学第一医院和北京大学深圳医院全科住院医师作为研究对象。两个医院均是“5+3”全科住院医师规范化培训基地,其中北京大学第一医院为“四证合一”的试点基地。结果　北京大学第一医院共发放问卷39份,回收有效问卷35份,有效回收率89.7%;北京大学深圳医院共发放84份问卷,回收有效问卷70份,有效回收率为83.3%。总体上,全科住院医师感觉到由于选择了全科专业而受到歧视,感觉作为全科医师能力不足。许多住院医师提到教学医师的教学态度较差。北京的住院医师比深圳的住院医师对培训更满意（P=0.001）,并觉得全科教学医师有足够的知识（P<0.001）和更合适的教学态度（P=0.004）,并且北京大学第一医院住院医师5项工作愿景得分均低于北京大学深圳医院,差异具有统计学意义（P<0.05）。结论　这些中国全科住院医师了解培训中需要改进的内容及培训的长项。北京全科住院医师对教学及工作满意度更高,其可以获得高水平教学医师的培训,并可以获得相关证明,提示教育改革可以增强培训力度并促进住院医师有更好的工作愿景。这些发现提示中国的住院医师面临着和国际相类似的情况,同时,也提示规范化培训教学课程的改革可能会带来益处。     

中美胸心外科住院医师培训的比较和启示

通过对中美两国胸心外科住院医师培训体系的培训前教育背景、培训制度及培训后执业方向进行比较,发现美国胸心外科住院医师培训入学门槛高、培养周期长、教育支出高,但其管理专业化、专科特点突出、评价体系完善,适合培养胸心外科专科医学人才。而我国目前的胸心外科住院医师培训尚需进一步完善,需借鉴美国住院医师培训体系的优点,制定更为合理和专业化的胸心外科住院医师培养方案,为我国培养优秀胸心外科专业人才。     

An American's view of Canadian medical education.

Undergraduate medical education in Canada and the United States is remarkably similar, except for the fact that Canadian medical schools are supported by their provincial governments. However, the systems diverge sharply at the postgraduate level. In Canada, the number and specialty mix of residents are negotiated by medical schools in response to educational and social needs; in the United States, these factors are largely determined by hospital service needs. The Canadian systems of accreditation, certification and payment for medical education after graduation are much simpler than those of the United States, and the accreditation and certification systems are more objective. In addition, the US system promotes subspecialization and a costly specialty imbalance, whereas Canada's system has achieved an appropriate balance of specialists and generalists. In general, Canadian medical education appears to be simpler, more accountable and more socially responsive.     

Graduate medical education

The annual surveys of residency programs on which this statistical report is based have had a higher than 95% response for the past four years. The number of accredited programs increased in 1984 and again in 1985, primarily as a result of the accreditation of additional subspecialty programs. Discussions about the sources and methods of financing graduate medical education may have an impact on the number and the size of programs in the near future. The count of available residency positions is a fluid entity and seems to be dependent on many factors, one of which appears to be the number of qualified candidates seen by program directors. The number of PGY-1 positions has not changed significantly over the past three years. The number of reported unfilled positions, including PGY-1 unfilled positions, has been declining since 1983. The special survey of PGY-1 programs conducted for the past three years reveals that about 10% of programs withdrew positions between October and July. However, another group of programs (some of which are new) added to the number of positions offered. The primary reason cited for withdrawing positions has changed. In 1983, the reason was cited as "financial" by 32% of program directors. In 1985, despite the national discussions about financing medical education, a financial reason was cited by only 16% of program directors. Reasons related to candidates, ie, "absence of suitable candidate" and giving the position to an "applicant at the PGY-2 or higher level," were cited by 49% of program directors in 1983 and by 67% in 1985. The total number of residents on duty (exclusive of newly accredited subspecialties) increased in 1983 and 1984 but decreased in 1985. Decreases were noted in family practice, internal medicine, pathology, and surgery. The number of new entry residents (PGY-1) decreased in 1983 (when the number of US graduates had decreased), increased in 1984, and decreased again in 1985. Forty-two percent of residents were training in family practice, internal medicine, or pediatrics. This statistic has not changed significantly over the past three years. (ABSTRACT TRUNCATED AT 400 WORDS)     

Migration of physicians from one specialty to another. A longitudinal study of US medical school graduates

To demonstrate the extent to which physicians change their specialty, randomized samples of the graduating classes of 1960, 1964, and 1968 were studied with respect to their self-designated specialties in 1971 and 1976. Of the 2,046 physicians in the three samples, 333 (16%) changed their specialty between 1971 and 1976. It was 8% for the 1960 cohort, 11% for 1964, and 29% for 1968. Of all the changes, 78% were from one specialty practice to another or back to a formal residency in a different specialty; 22% changed from one specialty residency to either practice or another residency in a different specialty. Between 1971 and 1976, a total of 127 (16%) of 783 primary care physicians changed their specialty. The magnitude of this change must be considered in planning for distribution of physicians by specialty.     

国外农村基层医师医学培养项目实施现状、成效及评价的系统综述

背景　2010年我国农村订单定向医学生免费培养工作启动，旨在为农村地区培养具备本科学历的全科医生，缓解农村地区基层医师匮乏的现状。本研究通过系统综述了解国外类似项目的实施现状、成效及评价，为我国农村订单定向医学生培养工作评价和改善提供理论参考。目的　了解国外农村基层医师医学培养项目实施现状、成效及评价指标方法等。方法　2019年2-7月，采用系统综述的方法，以“医学教育”“医学教育+医学本科生”“医学院校教育”“医学生”“住院医师规范化培训”“医学专业+人力资源”“农村地区”“农村基层医疗服务”“医师执业地点”“农村基层医师”“农村基层医师培养”“农村医学实习”“农村临床见习”为检索词，检索Ovid MEDLINE、PubMed、Cochrane及Google Scholar主要英文数据库，获取2000-01-01至2019-01-01发表的关于全球农村基层医师院校教育及住院医师培训等项目的实施现状、成效及评价的英文文献。结果　最终纳入53篇文献，分别来自美国、加拿大、澳大利亚、日本、泰国及南非6个国家，包括20个院校教育项目和6个住院医师培训项目。文献显示各国农村基层医师培养项目均具有指向性招生策略、面向农村卫生和全科医学的临床课程体系、以农村执业的家庭医生为临床导师及农村地区临床实践基地等要素；培养项目学生选择家庭医学为执业专业、农村地区执业率和长期农村保留率均明显高于非培养项目学生，两者国家医疗执照考试成绩和通过率无明显差异。长期农村地区临床实践培训、招生策略倾斜农村成长背景学生及农村执业的家庭医生导师是影响项目最终效果的关键因素。结论　医学教育是解决农村基层医师匮乏的有效途径。国外农村基层医师培养项目的招生策略、临床课程体系设置、导师指导及评价可为我国农村订单定向医学生培养工作提供有益参考。     

以“住-专一体化”为导向的分级带教模式在口腔颌面外科基地的实践研究

目的 以上海交通大学医学院附属第九人民医院口腔颌面外科基地为研究对象，探索“住-专一体化”分级带教模式在口腔颌面外科住培与专培中的实践效果。方法 在2022年6月至2023年4月期间，共计入组学员144名，其中试验组（住培72人、专培16人）和对照组（住培72人、专培16人）。分别采用传统模式与“住-专一体化”分级带教模式制订临床及学习任务，并记录学员在理论考核和自我评估中的表现。采用 SPSS 23.0进行t 检验。结果 “住-专一体化”分级带教模式在理论考核和学员自我评估中均取得了明显的效果。专培学员中，试验组（84.56±4.05）与对照组（81.13±2.78）之间分数差异具有统计学意义（P<0.05）。住培学员中，试验组（84.74±4.85）相对于对照组（82.10±4.34）表现更好，组间差异具有统计学意义（P<0.01）。自我评估问卷结果显示，试验组学员在多项自评指标中的积极评价比例高于对照组。结论 本研究的结果表明，“住-专一体化”分级带教模式为口腔颌面外科住培与专培教育提供了一种有效的教学模式。该模式有助于提高学员学科兴趣、促进临床实践能力，并为我国医学教育提供有益经验和未来发展方向。     

Oral Surgery: Present and Future

The history of the specialty of oral surgery is reviewed from the days of its origin, when it was essentially confined to exodontia, to its present status, in which it includes many and varied surgical operations relative to the human jaws and their associated structures. The scope and training pertinent to modern oral surgery are discussed. A three-year program on a graduate basis, required as partial fulfilment of the qualifications for accreditation and certification by the American Board of Oral Surgery, is described in detail. The need for mutual understanding by the medical and dental professions, as to what this specialty has to offer in terms of a total community health program, is emphasized.     

Graduate medical education, 1998-1999: a closer look.

Despite the ever-present risk of a critical imbalance in the physician workforce total numbers and specialty distribution, no systematic planning mechanism is in place. Furthermore, the length of training for graduate medical education (GME) precludes timely rectification of imbalances. We report GME activities collected in the American Medical Association Annual Survey of Graduate Medical Education Programs for 1998-1999, along with trends during the last 3 to 6 years. These data initially suggest that little has changed during the past several years; however, on closer examination, small but significant changes during the past 2 years may have serious consequences if continued. The total number of resident physicians, which has been constant during the last several years, decreased in 1998 by 760 from the previous year, while the number of programs continues to increase (6.1% since 1993). The number of US medical graduates entering GME programs remained stable during the last 6 years, the number of osteopathic graduates entering GME increased by 55.7%, and the number of international medical graduates (IMGs) entering GME continued to drop (down 13.2% since 1993). More IMGs tend to pursue additional training than do US graduates (in 1997, 32.9% vs 23.6%). Because IMGs are remaining in GME programs for longer periods, the total number of IMGs has not yet reflected significant change. About 62% of IMGs now entering GME training are either US citizens or permanent residents; ethnic minority residents are not decreasing in numbers as some predicted; and for the first time in the past 5 years, the primary care specialties have ceased their persistent growth. Toward the end of GME, the number of residents leaving programs before completion increased by 5.7% during the last 3 years. While some of these changes may be ascribed to reduced GME funding through the Balanced Budget Act of 1997, other factors clearly are at play. To anticipate future changes in the physician workforce, these factors should be identified to permit them to be monitored and modified as needed.     

The stability of early specialty preferences among US medical school graduates in 1983

Medical graduates in 1983 were in preclinical training when the Graduate Medical Education National Advisory Committee forecast a surplus of 70,000 physicians by 1990. Among the problems identified was the nuclear role of medical schools in affecting specialty choices. To understand this role further, the current study determined the stability and evolution of specialty preferences between the time of the Medical College Admission Test and the senior year of medical school. The study included 10,321 US medical school graduates in 1983. Eighty percent changed their specialty preference during this interval, demonstrating the substantial effects that medical schools have on specialty selection. The stability of early preferences ranged from 41% to 1%. Interest in primary care specialties declined among both men and women; interest in specialty care and supporting services increased during this five-year longitudinal study. These findings parallel shifts away from primary care among US medical school graduates in 1978 and 1983.     

Graduate medical education in the United States

The annual surveys of residency programs on which this statistical report is based have had a 95% or higher rate of response for the past five years. The number of accredited programs increased in 1986, primarily as a result of the accreditation of subspecialty programs in internal medicine. The largest number of programs is found in general internal medicine, followed by family practice, general surgery, and obstetrics/gynecology. More than one fifth of the programs are located in the Middle Atlantic region of the United States, with the largest number in the state of New York. The number of positions offered by accredited programs has increased as a result of the increase in the number of specialties with accredited programs. The number of GY-1 positions projected in the fall to be offered the following July has not increased significantly over the past three years. The reader is cautioned that the "number of positions offered" is affected by many factors and is subject to frequent change throughout the year. The number of residents on duty in ACGME-accredited programs increased in 1986 as a result of the increase in number of programs. However, the number of GY-1 residents on duty has decreased by 7% since 1984. This decrease is largely accounted for by the number of FMGs in GY-1 positions, a 21% decrease since 1984. This is especially evident in number of US citizen FMGs in GY-1 positions, a 38% decrease in the same time period. The specific factors that have caused the decrease in number of GY-1 FMG residents are not known at this time. One explanation might be a hesitation on the part of program directors to appoint new FMGs. Another factor could be the lower pass rate of US citizen FMGs on the FMGEMS, one qualification for appointment to an ACGME-accredited program. The number and percentage of women in residency programs continues to increase as it has over the past several years. For example, in 1977 women accounted for only 15% of residents; in 1986 they were 27% of residents on duty. Although female residents are found in nearly all disciplines, two thirds of them are training in family practice, internal medicine, obstetrics/gynecology, pediatrics, or psychiatry.(ABSTRACT TRUNCATED AT 400 WORDS)     

A preliminary analysis of accreditation criteria for surgical procedures by orthopedic residents

The study reported here represented a preliminary evaluation of the accreditation criteria for orthopedic operative procedures. Because selection of the criteria has not been guided by empirical data, the extent to which they accurately reflect resident clinical experience is of concern. To examine this question, residents in an orthopedic residency program were tracked for one year, and their activities were compared with the procedure requirements established by the Residency Review Committee (RRC) for Orthopaedic Surgery. The results indicated that the RRC categories unduly emphasized activities for which there was little patient demand and failed to distinguish or require some frequently performed procedures. In their present form, therefore, the designated categories were not found to cover adequately the content of current clinical practice and thus may not appropriately reflect educational needs.     

住院医师规范化培训与入训前学位培养的衔接

为了探索住院医师规范化培训与入训前学位培养的衔接,本文通过总结四川大学华西医院2003年以来开展的住院医师规范化培训与入训前学位培养的衔接工作,提出了按照入训前的专科工作情况和临床经验、培训一年后的考核结果、专家组意见和行政审批三者相结合的原则,建立住院医师规范化培训与入训前学位培养的衔接模式,为住院医师规范化培训和入训前学位培养的合理衔接提供了一种解决方案。     

层次培训模式在住院医师规范化培训中的效果评估简

目的评估层次培训模式在住院医师规范化培训中的效果。方法将新人职应届毕业生按照学历分为初、中、高三个级别,各级别接受不同年限培训,以住院医师规范化培训考核成绩对层次培训的效果进行反馈评估。结果培训总合格率在85．83％,初级、中级、高级合格率分别为88．89％,84．00％,84．62％。具有研究生学历的培训人员中,专业型学位的毕业生通过率高于科学学位人员。结论按照学历划分的层次培训模式在住院医师规范化培训中具有可行性和有效性。     

The crisis in primary care and the role of medical schools. Defining the issues.

While a number of issues have diminished the attractiveness of primary care residency programs to USGs, the absolute number of residents in these programs has increased rather than diminished over the past decade, although the proportion of USGs choosing these fields has decreased. In the current arena of medical practice, there are many reasons why these fields are not among the most attractive, and there are several remedies that could be applied to increase their attractiveness. Focusing on medical schools as the sole cause of this dilemma, however, is the least effective way of accomplishing this objective; in addition, this will allow those truly able to increase interest in these fields, such as state and federal governments, to have a reason for not doing so. As long as the medical marketplace is sufficiently large enough to accommodate more than the number of graduates from US medical schools in "desirable" residency training positions, one can never effectively "force" a choice of residency training, nor should one. Primary care can be among the most rewarding of specialties, if adequately supported. It is this support that is lacking and must be addressed.     

Graduate medical education in the United States

The annual surveys of residency programs on which this report is based have had a higher than 90% response rate for the past 5 years. The count of available residency positions is a fluid entity and seems to be dependent on many factors, including funding and the number of qualified candidates seen by program directors. The number of GY-1 positions has not changed significantly during the past 3 years. The number of reported unfilled positions, including GY-1 unfilled positions, has increased each year since 1985. The total number of residents on duty decreased slightly in 1988. This decrease may be due to a lower response rate. The number of new entry residents (GY-1) has been decreasing since 1985. Thirty-nine percent of residents were training in family practice, internal medicine, or pediatrics. The number and percent of women in residency programs have remained steady. The percentage of FMG residents decreased slightly to 15.3% in 1988. The number of black non-Hispanic residents decreased in 1988, and the percentage of all residents who are black decreased slightly. The number of graduates of osteopathic medical schools in ACGME programs has increased 39% since 1986. The number of institutions involved in graduate medical education has not changed significantly during the past 3 years, although the number of institutions that are not hospitals has increased since 1983. Ninety-five percent of all types of institutions have some type of affiliation with a US medical school.     

Pediatric resident staff follow-up, 1958 to 1972: their present place of practice and activities.

Of 174 medical graduates who had undertaken residency training in pediatrics at the Health Centre for Children, Vancouver between 1958 and 1972, 156 replied to a questionnaire designed to determine their present activity. Excluding those still in training 58.4% are currently practising pediatrics, 28% are in family practice and 12.8% are in other areas of professional activity; 49% obtained a specialty degree in pediatrics and 5.4% obtained certification of the Royal College of Physicians and Surgeons of Canada in another specialty. Of the total, 69% have remaind in Canada; of the Canadian graduates 83% have remained in this country, compared with 63.8% of graduates from other countries. Estimation of pediatric manpower requirements should take into account the anticipated increase in population, the pediatrician attrition rate, the contribution one province may provide for the rest of the country, and the fact that only approximately 60% of pediatric trainees will ultimately practise this specialty.