"일에서 교육으로" -20세기 미국 의사 수련제도 형성의 역사- = From Work to Education: The Transformation of the Graduate Medical Education in 20th-Century United States

다국어 초록 (Multilingual Abstract)

The process of becoming a physician in the United States evolved from the late 19th century to the present. The internship and residency programs, which comprise the physician training system in the United States, have dual origins. The most well-known formal residency program was initiated in 1889 at Johns Hopkins University and influenced by late 19th-century German universities. Since physician training is also rooted in apprenticeship, the residency system has had to balance these two origins by remaining committed to providing elevated professional training while satisfying the desire to run hospitals with cheap labor.
Graduate Medical Education (GME) took a long time to become standard practice in hospitals. After graduating from medical school, the modern training regimen began with the residency program initiated at Johns Hopkins Medical School. This became the model for medical schools nationwide. Johns Hopkins University aimed to produce “scientific practitioners” who relied on the same methods of reasoning in medical practice as in the laboratory. Since its inception, the two main purposes served by the residency program have been to provide education for residents and medical services for hospitals. These services included not only patient care but also additional responsibilities outside of medical education. By the 1930s, most medical school graduates undertook internships to prepare for general practice, and some received additional training through residency. By that time, residency was the sole path toward medical specialization. Before World War I, residency programs spread across the country, debuting as initiatives to train researchers and faculty in specialties. By World War II, the purpose of residency training shifted to producing clinical specialists.
The establishment of Medicare and Medicaid led to a surge in hospital clinical duties. By the 1960s, internship opportunities outnumbered the number of medical school graduates. Faced with difficulty securing interns, the existing internship and residency systems were merged into one residency program with a first-year internship. The rise of managed care since the 1970s caused hospitals to expand their patient care responsibilities, and the education of and respect for interns and residents dwindled, despite their crucial role as hospital staff. This led to a fierce backlash among residents nationwide. They complained about prolonged working hours and overwhelming tasks, and their dissatisfaction with the work environment directly impacted patient care. Beginning in the 1980s and persisting throughout the 1990s, ongoing efforts to cut healthcare costs led residents to care for larger numbers of patients in less time. This diminished the educational value of the residency experience and raised concerns for patient safety within the system. The medical profession has been searching for solutions to respond to the challenges within residency programs, especially the prevalence of prioritizing work over education that emerged decades earlier. The history of the physician training system in the United States is marked by this continuous struggle to prioritize education over work.