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zoom RSS カリブの医学校/米国医療事情 ニューヨーク

<<   作成日時 : 2010/12/30 02:06   >>

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 カリブの医学校が、3−4年次に米国の特にニューヨーク州の病院でトレーニングを受けられると約束することで、小さな島には数千人の米国学生が集まっている。
 医療専門職や学会に対するプレッシャーがかかる激しい縄張り争いのために州の16の医学校は外国の競争相手を攻撃している。州評議会を説得して外国の学校がキャンパスの拡張としてニューヨークの病院を使うことを不可能でないにしてもより難しくさせるための攻撃的なキャンペーンを開始した。
 米国での医師ライセンスを取るために必要な実地研修を提供するには、小さな島には病院がないので、承認されると少なくともいくつかのカリブの学校は危ない状況になるという。医学教育や国内医師ライセンスについての大きな論争にもなっている。
 米国では毎年42,000人以上の学生が医学校を目指すが、入学するのは約18,600人であり、拒絶された学生は外国の学校をめざす。米国のレジデントの1/4以上はカリブなど外国の医学校の出身者である。米国では2020年には90,000人の医師が不足するすると予想されており、こうした卒業生は米国内で教育を受けた卒業生よりも外科など高収入の専門医よりプライマリケアや家庭医になる傾向があるので、こうした学校はそのニーズを満たしているとしている。
 ニューヨーク州は医学生やレジデントの数が最も多い州であるため、外部からの流入の影響を受け、トレーニング病院での競争が起こることが数十年の懸案となっている。
 営利団体であるカリブ最大の医学校は、数百万ドル支払ってニューヨークの病院を買収しているという。伝統的に米国の医学校は金銭を支払うことなく、病院は大学との関連を名声として誇る。学生が資格取得するための営利訓練工場として考えるのは良くないのではないか。
 ニューヨーク州の学校は、米国医師会の「外国の医学校の中心的な臨床のカリキュラムはその学校で提供されるべきであり、米国の病院がその代わりをするべきではない」という立場を州として採用すべきと主張している。
 外国の学校は国内と同じ認定システムを採用していない。6月に出されたレポートによれば、医師ライセンス試験の合格率は外国で訓練された学生は低いという。しかしここ10年でそのギャップは縮まり、1998年の57%から2008年には75%に上がった。米国とカナダの学校では2008年に94%であった。しかし同じレポートで、懲戒・誤診の医師の割合は差がなかった。
 多くの学生が国内の医学校に入学できなかったため外国にでている。現在約4,400人の3−4年生がニューヨークの病院で研修していて、医師不足のためにさらに15-30%増やす必要があるという。州当局によれば、外国の学校から2,200人が来ていて、その90%以上はカリブからである。セントジョージズだけで約1,000人、10年で1億ドルの契約を市保健局・病院協会(公的病院を経営している)と結んでいる。市の関係者はニューヨークの学校が敬遠する貧困地区の病院に学生を配置するという契約を擁護している。臨床研修した学生はレジデントや医師として戻ってきてくれるという。
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外国人医師が支える米国医療/米国医療事情
http://kurie.at.webry.info/201008/article_11.html
医学生に不人気なプライマリー・ケア医/米国医療事情
http://kurie.at.webry.info/200809/article_17.html
優秀な医学生がめざす分野/米国医学生事情
http://kurie.at.webry.info/200803/article_32.html
プライマリ・ケア崩壊へ/米国医療
http://kurie.at.webry.info/200706/article_49.html
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Medical Schools in Region Fight Caribbean Flow
http://www.nytimes.com/2010/12/23/nyregion/23caribbean.html
By ANEMONA HARTOCOLLIS
Published: December 22, 2010

画像For a generation, medical schools in the Caribbean have attracted thousands of American students to their tiny island havens by promising that during their third and fourth years, the students would get crucial training in United States hospitals, especially in New York State.

But in a fierce turf battle rooted in the growing pressures on the medical profession and academia, New York State’s 16 medical schools are attacking their foreign competitors. They have begun an aggressive campaign to persuade the State Board of Regents to make it harder, if not impossible, for foreign schools to use New York hospitals as extensions of their own campuses.

The changes, if approved, could put at least some of the Caribbean schools in jeopardy, their deans said, because their small islands lack the hospitals to provide the hands-on training that a doctor needs to be licensed in the United States.

The dispute also has far-reaching implications for medical education and the licensing of physicians across the country. More than 42,000 students apply to medical schools in the United States every year, and only about 18,600 matriculate, leaving some of those who are rejected to look to foreign schools. Graduates of foreign medical schools in the Caribbean and elsewhere constitute more than a quarter of the residents in United States hospitals.

With experts predicting a shortage of 90,000 doctors in the United States by 2020, the defenders of these schools say that they fill a need because their graduates are more likely than their American-trained peers to go into primary and family care, rather than into higher-paying specialties like surgery.

New York has been particularly affected by the influx because it trains more medical students and residents ― fledgling doctors who have just graduated from medical school ― than any other state. The New York medical school deans say that they want to expand their own enrollment to fill the looming shortage, but that their ability to do so is impeded by competition with the Caribbean schools for clinical training slots in New York hospitals.

Their argument is one that has been lobbed at Caribbean schools for decades: that those schools turn out poorly trained students who undercut the quality of training for their New York peers learning alongside them at the same hospitals.

And they complain that the biggest Caribbean schools, which are profit-making institutions, are essentially bribing New York hospitals by paying them millions of dollars to take their students. The American medical schools traditionally pay nothing, because hospitals like the prestige of being associated with universities.

“These are designed to be for-profit education mills to train students to pass the boards, which is all they need to get a license,” said Dr. Michael J. Reichgott, a professor at the Albert Einstein College of Medicine in the Bronx.

Charles Modica, chancellor of St. George’s University in Grenada, whose first class started studying in 1977, making it one of the oldest in the Caribbean, said the New York deans were simply afraid of competition.

“It’s basically a situation where the New York State deans just can’t hold their noses high enough up in the air, and I think it’s disgraceful,” said Mr. Modica, who founded St. George’s after he was rejected from medical school and went on to law school. Most Americans had never heard of the school until 1983, when President Reagan sent troops into Grenada, partly, he said, to rescue St. George’s American students from unrest.

The debate is so fraught that officials of Ross University, on the island of Dominica, were at first reluctant to talk about it, fearing students would be scared away from offshore schools.

“If the domestic schools felt we were taking opportunities away from their students, if they can specifically tell us what location we were taking them away from ― that question was never answered,” said Dr. Nancy Perri, Ross’s chief academic officer.

The New York schools want the state to adopt the position of the American Medical Association, that “the core clinical curriculum of a foreign medical school should be provided by that school and that U.S. hospitals should not provide substitute core clinical experience.”

Under their proposal, the foreign schools could send students to New York only for electives, in their fourth year, not for core training, in their third. Short of that, the domestic schools want to stop any more foreign schools from sending students to New York for long-term clinical training while the state studies how it approves the schools.

The foreign schools do not go through the same accreditation process as the United States schools. So the state has its own process for approving foreign schools, but the New York schools contend it is not as thorough as the national accreditation process, and it should be.

The Regents are struggling to compare the academic and professional performance of students from the domestic and foreign schools. The Government Accountability Office, a federal agency, tried to do so in a report aimed at determining whether the foreign schools should continue to qualify for federal loans.

The report, issued in June, found that on average, foreign-trained students lagged behind their American-trained peers in passing the medical licensing exams. But over the last decade, they had narrowed the gap, especially in the clinical knowledge portion of the exams, which 75 percent of foreign-educated Americans passed on the first try in 2008, up from 57 percent in 1998. For students in American and Canadian schools, which are subject to the same accreditation process, the rate was 94 percent in 2008, about the same as 10 years earlier.

The report found few differences in the rates of disciplinary actions or malpractice payments between physicians educated abroad and in the United States.

A memorandum submitted to the Regents this month by Frank Mun~oz, a deputy state education commissioner, suggested that the top Caribbean schools, like St. George’s, American University of the Caribbean and Ross, have been successful at establishing their academic merit.

“There is evidence,” Mr. Mun~oz said, that the more mature Caribbean schools “admit students with very competitive backgrounds. It appears that many of these students were not granted admission to domestic schools because of the limited number of available seats.”

The New York schools say they now send about 4,400 of their students to New York hospitals for clinical training in their third and fourth years, and would need to expand that by 15 to 30 percent to help solve the doctor shortage.

Foreign schools send about 2,200 students, more than 90 percent of them from the Caribbean, according to the state. St. George’s alone sends about 1,000 students, many through a 10-year, $100 million contract with the New York City Health and Hospitals Corporation, which runs public hospitals. (A high-ranking St. George’s official, who also sat on the board of the city hospitals corporation, was fined for a conflict of interest for his role in soliciting clinical training slots for the school.)

City hospital officials have defended the contract with St. George’s as a way of getting students into hospitals in poor neighborhoods that have been shunned by New York schools. Once they have done their clinical training in those hospitals, the students often return as residents and then as full-fledged attending physicians, officials said.

But New York deans say the hospitals are taking too many students. “There are realistic limits to the number of students that can be placed in any one clinical environment and have a high-quality education take place,” said Dr. Lawrence G. Smith, dean of the Hofstra North Shore-LIJ School of Medicine, which will accept its first class of 40 students next fall.

The issue, which was reported this month in the Chronicle of Higher Education, is so charged that the city’s hospital trade group, the Greater New York Hospital Association, has declined to take a position. State officials say it is unclear just how many clinical trainees New York hospitals could reasonably accommodate, and they are surveying the hospitals to try to determine that.

Meanwhile, St. George’s continues to turn out doctors like Janine Reinhardt, 27, who grew up in Massapequa, N.Y., had a 3.97 grade-point average as a biology major at Cornell, but scored 27 on the MCAT. She said she probably needed a score of 30 to get into an American school.

Dr. Reinhardt graduated from St. George’s this year, and is now a resident in emergency medicine at Stony Brook University Medical Center, which was her first choice. She said her underdog status as a St. George’s student had made her work harder.

“At St. George’s, we’re rejected from the U.S. schools and then we feel we have something to prove, as opposed to the sense of entitlement that some U.S. medical students might feel,” Ms. Reinhardt said.


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