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

Implementation,Outcome,and Evaluation of Rural Primary Care Physicians Training Programs in Foreign Countries:a Systematic Review

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。

Background The rural-oriented tuition-waived medical education(RTME)program has been launched in China since 2010,aiming to provide rural areas with more primary care physicians with medical undergraduate education to address the shortage of rural physicians.We systematically reviewed the implementation,outcome and assessment of similar medical education programs among foreign countries,offering theoretical insights into the evaluation and improvement of RTME programs in China.Objective To understand the implementation,outcome,and assessment of rural physician training programs in foreign countries.Methods The databases of Ovid MEDLINE,PubMed,Cochrane Library and Google Scholar were electronically searched from February to July 2015 for English language articles published between 2000-01-01 and 2019-01-01 regarding the implementation,outcome and assessment of medical training programs for rural primary care physicians and residents in foreign countries.The search terms used were as follows:"as Googlescholar""medical education+medical undergraduate student""medical college education""medical student""standardized residency programs""medical specialty+human resource""rural area""rural primary healthcare service""physician practice location""rural primary care physician""rural primary care physician training""rural medical internship",and"rural clinical clerkship".Results This study eventually included 53 articles coming from six countries comprising the US,Canada,Australia,Japan,Thailand and South Africa,with 20 medical college programs and 6 residency programs described.Key components consisting of specific enrollment strategies,clinical curriculum highlighting both rural medicine and general practice,mentorship of family physicians practicing in rural areas,and rural clinical practice bases were shared amid the 26 programs.Compared to graduates of non-rural training programs,graduates of rural training programs exhibited significantly higher rates of choosing family medicine as practice specialty,practicing in rural areas,and retaining in rural areas for a long time.No prominent differences were detected between both types of graduates regarding mean scores as well as passing rate of the national medical licensing examination.Long-term rural clinical clerkship,specific enrollment strategies favoring rural background,and mentorship by family physicians practicing in rural areas were key factors associated with ultimate outcomes of those programs.Conclusion Medical education is an effective solution to address the shortage of rural primary care physicians.Enrollment strategies,clinical curriculum development,mentorship,as well as assessments from these foreign rural primary care physician training programs may provide helpful suggestions for RTME programs in China.