Institute of International Medical Education

Advisory Committee MeetingNew York, June 22-23, 2000

PANAMERICAN FEDERATION OF ASSOCIATIONS OF MEDICAL SCHOOLS.

PAFAMS

An international challenge and opportunity for collaborative action in medical education and health

Mission

The Pan American Federation of Associations of Medical Schools (PAFAMS/FEPAFEM) is

an international, non governmental, academic organization, dedicated to the

development and improvement of medical education in the Continent.

FEPAFEM

FEDERACIONFEDERACIONPANAMERICANAPANAMERICANADE ASOCIACIONESDE ASOCIACIONESDE FACULTADESDE FACULTADES[ESCUELAS][ESCUELAS]DE MEDICINADE MEDICINA

PANAMERICAN

FEDERATION OF

ASSOCIATIONS

OF MEDICAL

SCHOOLS

PAFAMSPAFAMS

OFFICE OF EDUCATIONAL RESOURCESOFFICE OF EDUCATIONAL RESOURCES

ORGANIZATIONORGANIZATION

PAFAMSPAFAMS

VICE-PRESIDENTVICE-PRESIDENT

PRESIDENTPRESIDENT

TREASURERTREASURER

VocalNorth America

VocalNorth America

VocalSouth America

VocalSouth America

VocalCaribbean and

Central America

VocalCaribbean and

Central America

Administrative CommitteeAdministrative Committee Executive DirectorExecutive Director

PAFAMS office of Educational Resources - Bogotá

PAFAMS office - Caracas

PAFAMS office of Educational Resources - Bogotá

PAFAMS office - Caracas

The organization comprises twelve National Associations of Medical Schools and individually affiliated

Medical Schools.

COMPOSITION

MEDICAL SCHOOLSaffiliated

385

FACULTY

~>50,000MEDICAL STUDENTS

>500,000

CHRONOLOGY

Decision to create PAFAMS, Montevideo, Decision to create PAFAMS, Montevideo, 19601960

Created in Viña del Mar, Chile, in 1962Created in Viña del Mar, Chile, in 1962

The Council started operations in Poços The Council started operations in Poços de Caldas, Brasil, in 1964de Caldas, Brasil, in 1964

PAHO recognized PAFAMS as NGO 1965PAHO recognized PAFAMS as NGO 1965

Headquarters in Bogota until 1976Headquarters in Bogota until 1976

Office of Educational Resources in Bogota Office of Educational Resources in Bogota since 1977since 1977

Headquarters transferred to Caracas 1977Headquarters transferred to Caracas 1977

ACTIVITIES 1968-1976

Curriculum Demography International Courses on Health and

Population Continental Program on Information

over Medical Education (PCIEM) Program on Information &

Documentation Centers on Medical Education and Health (CIDEMS)

ACTIVITIES 1977-1986

Community Medicine Development of Medical Education

Standards (PRODEEM) Analysis of Teaching / Service

Integration (PROAIDA) Family Medicine Program Latin American Program for the

Development of Odontological Education (PROLADEO)

ACTIVITIES 1992-1995

Social Service and Community Program Prospective Analysis of the Health of

Women, Children and Adolescents Communitary Social Service Program Panamerican Program for the

Development of Medical and Health Information (PANET)

ACTIVITIES 1995-1996-1997

Information and Management System for the descentralization of the Venezuelan National Health System

Venezuelan Network of Health Information Data Bases: Medical Schools, Medical Libraries, Health Institutions.

Information and Documentation Center in Medical Education and Health (CIDEMS)

· Health information systems. Related to Venezuelan Ministry of Health process of decentralizing of Health Services.

· Venezuela National Health Information Network.

· Strategic Communications. INFORMATICS 2000

· Information & Telecommunications Technologies applied to the Medical Education.

· Documentation and information Center for Medical Education and Health

Working programs 1995-1998

11

22

33

44

55

HOW MEASURED?

CONTINUING EDUCATION

PHYSICIAN’S RELATIONSHIP TO PATIENTS

How much does it cost?

RESEARCH

Everywhere, through media and private organizations

Related to groups of patients

Limited to research orientated institutions

Source: Panamerican Federation of Associations of Medical Schools, 1995-99

Major changes in health care delivery and medical practice in Latin America 1997 - 2000

TECHNOLOGY

MISSION

Complex, a matter of distinction

Prevention, health maintenance

1515 1,4831,483 9.29.2 1,8601,860

77 49 49 3.63.6 142 142

88 47 47 4.04.0 105 105

100100 1,7021,702 8.08.0 329 329

EstablishedEconomies

Ex-SocialistEconomies(Europe)

LATINLATINAMERICAAMERICA

WORLDWORLD

Fuente: World Development Rtport 1993: Investing in Health/World Bank. Washington: WB., 1993Fuente: World Development Rtport 1993: Investing in Health/World Bank. Washington: WB., 1993

RegionRegion%%

World World PopulationPopulation

ExpenditureExpenditure(billions $)(billions $)

%%PTBPTB

in Healthin Health

per capitaper capitaInvestmentInvestment

U.S.$U.S.$

INVESTMENTS & HEALTH EXPENDITURE

19801985

19901995

0

200

400

600

800

1.000

1.200

1.400

Venezuela: Health Budget in Real Terms (US$)

MD/10,000

Country 1979 1990 Δ%

Argentina 26.7 26.8 0.4%

Brazil 8.7 13.6 56.3%

Colombia 5.1 10.9 113.7%

Costa Rica 6.6 12.6 90.9%

Chile 5.2 11 111.5%

México 8 17 112.5%

Panamá 8.5 16.4 92.9%

Venezuela 11.4 16.2 42.1%

Medical Schools in Latin America

1960 1992

196 418

Medical students

513,271 537,106

1985 1992

Relación Aspirantes/Admitidos

1980 12,011981 13,631982 11,141983 13,641984 13,551985 11,531986 10,211987 9,501988 8,711989 8,671990 9,691991 9,261992 9,291993 10,001994 9,01 1995 8,041996 7,591997 7,371998 6,90

RelaciónAspirantes/Admitidos

por FacultadesPúblicas yPrivadas

1980-1998

1980 20,92 6,851981 24,12 7,191982 19,02 6,611983 21,51 8,091984 20,11 8,521985 17,31 7,801986 14,72 6,961987 14,81 5,621988 12,52 5,571989 12,57 5,641990 14,89 5,681991 16,11 4,961992 15,44 4,851993 16,45 5,091994 16,35 4,03 1995 13,48 4,221996 14,29 3,651997 14,96 3,121998 14,77 2,61

Año Públicas Privadas

CONFERENCIAS PANAMERICANAS DE EDUCACION MEDICACONFERENCIAS PANAMERICANAS DE EDUCACION MEDICA

VII 1978 El Médico General FamiliarNew Orleans, EUA

VIII 1980 Estrategias para la Formación del Médico General FamiliarPanamá

IX 1982 * Educación Médica Continua* Formación del Médico General o de Familia* Formación de Recursos Humanos

para la Medicina del Año 2000Buenos Aires

X 1984 Innovación y calidad de la Educación MédicaBogotá

XI 1989 Evaluación de la Educación MédicaMéxico

XII 1989 Factores Críticos en Educación MédicaMontreal, Canadá

XIII

XIV 1993 Desarrollo de la Información de la Investigación Científica y de la Biotecnología y su Impacto en la Educación Médica

Quito, Ecuador

XV 1997 La Educación Médica en el Tercer MilenioBuenos Aires

CONFERENCIAS PANAMERICANAS DE EDUCACION MEDICACONFERENCIAS PANAMERICANAS DE EDUCACION MEDICA

PAFAMSPAFAMS

ACCREDITATION & EVALUATIONACCREDITATION & EVALUATION PROGRAMSPROGRAMS

• Curriculum Seminars (Curriculum Seminars (1969-1972)1969-1972)

• Development of Standards in Medical Development of Standards in Medical Education (PRODEEM - PAHO ) Education (PRODEEM - PAHO ) (1979-(1979-1981)1981)

• Self-evaluation Self-evaluation (1983-84)(1983-84)

• Prospective Analisis Prospective Analisis (1985)(1985)

ACCREDITATION & EVALUATIONACCREDITATION & EVALUATION PROGRAMSPROGRAMS

• XI PanAmerican Conference on Medical Education , Mexico (1986)

• Latin-American Program for the Development of Medical Education , (PRODEEM), ( 1987 )

• Integration of Teaching and Health Care Delivery , PROAIDA, W.K. Kellogg Fundation.

• Medical Ed. In the Americas, WKKF-ABEM (1989-91)

PAFAMS PAFAMS ACCREDITACION & EVALUATION ACCREDITACION & EVALUATION

PROGRAMSPROGRAMS

• PanAmerican Health Organization Programs , Evaluation and Standards, (1996-99).

• WFME, International Standards for Med.Education, ( 1999- )

• China Medical Board Programs : Institute for International Medical Education (1999- )

Why are they needed ? What is being done in each country ? Who is in charge ? Legislation and framework Methodologies & Systems approach Participants Impacts and Benefits Surveys and facts Peer review

PAFAMSPAFAMSACCREDITATION PROCESSESACCREDITATION PROCESSES

THE PRACTICETHE PRACTICEOF MEDICINEOF MEDICINE

PROFESSIONAL

ACTIVITY

• MORAL COMMITMENTMORAL COMMITMENT

• SELF-REGULATIONSELF-REGULATION

• INTELECTUAL AUTONOMYINTELECTUAL AUTONOMY decision makingdecision making

PROFESSIONALISMPROFESSIONALISM

• KNOWLEDGEKNOWLEDGE

CERTIFICATIONCERTIFICATIONFEPAFEM / FELACFEPAFEM / FELAC

legal vs. voluntarylegal vs. voluntary

NATIONAL / REGIONALNATIONAL / REGIONALMinistries of Education / HealthMinistries of Education / Health

National or Regional BoardsNational or Regional Boards

UNIVERSITYUNIVERSITYSchools of MedicineSchools of Medicine

Associations of Medical SchoolsAssociations of Medical Schools

PROFESSIONALPROFESSIONALSpecialists SocietiesSpecialists Societies

CERTIFICATION CERTIFICATION and and ACCREDITATIONACCREDITATIONin Latin Americain Latin America

2- PAFAMS Medical Schools

3- FELAC Professional surgical organizations

IIMEInternational Standards for Medical Education

1- PAHO Ministries of Health

CERTIFICATIONCERTIFICATION

VERSUSVERSUS

ACCREDITATIONACCREDITATION

NATIONALNATIONAL

PROVINCIALPROVINCIALVERSUSVERSUS

INTERNATIONALINTERNATIONAL(common market)(common market)

• GOVERNMENTGOVERNMENT• UNIVERSITYUNIVERSITY• PROFESSIONALPROFESSIONAL

• CENTRAL AMERICANCENTRAL AMERICAN• ANDEANANDEAN• MERCOSURMERCOSUR• BILATERALBILATERAL

CERTIFICATION CERTIFICATION and and ACCREDITATIONACCREDITATION

in Latin Americain Latin America

-Ministry of Education Council on Higher Education - Ministry of Health Provincial Secretaries of Health

- Association Med. Schools- Professional organizations Specialists

- PAFAMS Medical schools - PAHO Mnistries of Health

- FELAC Specialists

NATIONAL REGIONAL

CERTIFICATION CERTIFICATION and and ACCREDITATIONACCREDITATION

in Latin Americain Latin America

PAFAMSPanamerican Federationof Medical Schools

PAHOPanamerican Health Organization

Ministry of EducationCouncil for Higher EducationCouncil on Certificationand Accreditation

Ministry of HealthProvintial Secretaries of Health

CONGRESSIONALACTS

VOLUNTARY

CERTIFICATION

Purpose:

To define and, through credentialing,

implement requirements

of education and

standards of practice

in the medical specialties

LATIN AMERICA

• Increase in the number of physicians and specialists

• Increase in the number of medical shools

• Diversity in credentialing systems

proliferation of undergraduate and graduate programs

Quality ?

Number of specialistsas % of total physicians

LATIN AMERICA

ChileVenezuela

50 – 75 %

BelgiumFranceGermany

25 – 50 %

too many specialists ?

SPECIALISTSPECIALIST

PositivePositive NegativeNegative

• best quality of care in complex diseases• high standards of practice• promotes research and education

• high costs ???• leads to “ultra”specialization• promotes increase in medical procedures

Even when specialists perform as

general practitioners, there remains

a trend to generate a greater number

of examinations and procedures.

Charles E. LewisNew Engl J Med 1969

S P E C I A L I S T

• Body of specialized knowledge intellectual capital• Residency Graduate programs Accreditation WHO ?• Certification Credentialing WHO ?

MEDICAL SPECIALTIES

• Which ? different recognition in different nations Example : Mastology• Name of specialty Different meaning Example : Traumatologist

• Data & statistics inadequate

“Medical specialties seem to be a

constantly expanding phenomenon

in Latin America in the

twentieth century.”

Pan American Health OrganizationPan American Health OrganizationDecember, 1999December, 1999

“The proliferation of specialties

appears as a long-term trend.”

Medical specialties – credentialing (1996-99)

Country No. specialties Credentialing Nature body

Argentina 50 Ministry of Health Public

Brazil 66 Federal Medical Public Council Public

Chile 38 CONACEM Non Gvt.

Colombia 40 ASCOFAME Non Gv.t

Costa Rica 91 Assoc. Phys. Surgs Profess.assoc.

Mexico 47 Nat’l Acad. Med. Non Gvt.

Panamá 53 Techn. Council Council Public

Venezuela 45 Venezuelan Med. Profess. Federation assoc

CREDENTIALINGArgentina

1995: Congressional Bill 24.501/95

Ministry of Education, University Council:

standards for medical education

(undergraduate, graduate, postgraduate)

National Council for University Evaluation

and Accreditation (CONEAU)

Role of AFACIMERA,(Med.Schools )

CREDENTIALINGArgentina

Medical degree

Residency

Specialtycertificate

Re-certification

University

University, Specialty Societies,Ministry Secr. of Health,

National Academy of Medicine

Universities,financed by Ministry of Health

Provincial Secretaries of Health

National Academy of MedicineColegio Médico Argentino

CREDENTIALINGBrazil

Federal Gvt. has no nothing to do with specialties

March 4, 1991:Interinstitutional Commission

for Evaluation of Medical Education(CINAEM)

• Brazilian Association of Medical Education• Brazilian Medical Association• Council of Chancellors of Universities• Federal Medical Council• National Academy of Medicine• and 6 other organizations

CREDENTIALINGBrazil

November 24, 1995:

National Education Council

Interinstitutional Commissionfor Evaluation of Medical Education

(CINAEM)

EVALUATION

CREDENTIALINGCOLOMBIA

Certification as specialist is a private and voluntaryaffair, and is done by ASCOFAME.

Certification is issued upon completion o anapproved graduate program by the

Specialties Committee, which also definesminimum training requirements.

Accreditation of programs is by theNational Council on Higher Education’s

National Accreditation Council

CREDENTIALINGCOLOMBIA

Congressional Bill No. 30, 1992

National Accreditation System

National Accreditation CouncilMinistry of Education

acts through selected academic peers

ASCOFAME

Ministerio de Salud Pública

RECURSOS HUMANOS PARA LA SALUDY LA EDUCACION MEDICA

EN COLOMBIA

Conferencia Nacional de ResultadosAgosto 9 de 1967

Ediciones Tercer MundoASOCIACION COLOMBIANA DE FACULTADES DE MEDICICNA

ASCOFAME

RECURSO HUMANO EN MEDICINA:

FORMACION, DISTRIBUCION

Y BASES PARA UNA PROPUESTA POLITICA

ASOCIACION COLOMBIANA DE FACULTADES DE MEDICINA2000

ASCOFAME

ASOCIACION COLOMBIANA DE FACULTADESDE MEDICINA

SITUACION Y FUTURO DE LAS ESPECIALIDADES

MEDICO-QUIRURGICAS EN COLOMBIADocumentos Varios

Santafé de Bogotá, mayo de 2000

CREDENTIALINGCHILE

Autonomous National Corporation for theMedical Specialties, CONACEM

• Medical Association of Chile (Colegio Médico)• Specialty Societies• Institute of Chile (Academy of Medicine)• Assoc. of Medical Schools of Chile (ASOFAMECH)• Ministry of Health (observer)

Certification of specialties andissues corresponding Title

CREDENTIALINGMEXICO

Specialists CouncilsNational Academy of MedicineNational MedicalAssociation

Interinstitutional Council on HumanResources for Health

co-chaired by Ministers of Health and Education

Accreditation: led by the Mexican Assoc. of Med. SchoolsNational Accreditation System

77 medical schools: 54 belong to PAFAMS

150,000 MD’s (25,000 not in practice)

45,000 accredited by the Specialists Councils

PAFAMS PAFAMS ACCREDITATION PROCESSES ACCREDITATION PROCESSES

PERÚ:CONAFU, Council for the Accreditation of

Medical SchoolsASPEFAM, promotes the development of a

National Accreditation System Governmental Council is in Charge

.

PAFAMS PAFAMS ACCREDITATION IN LATIN AMERICAACCREDITATION IN LATIN AMERICA

PANAMA:Ministry of Health: Creates National Council of

Accreditation of Health Human Resources .

VENEZUELA: On going programs of the Venezuelan Ass. Of

Medical Schools [ AVEFAM ] and the Venezuelan Medical Federation

MEDICAL ACCREDITATION AND SPECIALTIES IN L. A.Conclusions

• Constant expansion in past 3 decades along increase in number of Med. Schools

• Many specialties - a few concentrate large numbers - ecnomic and medicolegal factors

• No. of specialists costs

• Regulation Public (legal norms)

Private (voluntary)

• Increasing medical unemployment

?

• Social security reforms against specialists

DESPROFESIONALIZACION

BUROCRATIZACION

CORPORATIZACION

PROLETARIZACION

“Managed Care”ATENCION MEDICA

GERENCIADA

MEDICINA

=Interme -

diación

DESPROFESIONALIZACION

BUROCRATIZACION

CORPORATIZACION

PROLETARIZACION

“Managed Care”ATENCION MEDICA

GERENCIADA

MEDICINA

CIENCIA

PROFESION

A U D I T O R I Anecesaria

Managed CareATENCION MEDICA

GERENCIADA

MMEEDDIICCOO

UUSSUUAARRIIOO

Sala Teológica, Monasterio Strahov, Praga (1671 )Frescos Educación y Sabiduría (1721-27 )

microscopio

INTERNET:INTERNET:

19901990 19911991 19921992 19931993 19941994 19951995 19961996 19971997

00 592592 37633763 930493042021420214

3430034300

102430102430

169635169635

Host Computers GrowthHost Computers Growth

PAFAMS / PAFAMS / CenternetCenterneton going on going survey: survey: satellite access satellite access &&capabilitiescapabilities(base (base 550) 550)*

*

USA * [+ 102 Academic Health Centers]

D.R.

15

11

Answers Answers 57 57 * + others on going* + others on going

*

ACTION LINESACTION LINES

MEMBERSHIP INTERLINKMEMBERSHIP INTERLINK ACCREDITATIONACCREDITATION CURRICULUM INNOVATIONCURRICULUM INNOVATION INFORMATION TECHNOLOGYINFORMATION TECHNOLOGY HEALTH & SOCIAL REFORMSHEALTH & SOCIAL REFORMS MANAGEMENT MANAGEMENT ETHICS & VALUESETHICS & VALUES

A MAJOR CHANGE IN A MAJOR CHANGE IN MEDICAL MEDICAL EDUCATION HAS EDUCATION HAS BEEN THE BEEN THE RECOGNITION THAT RECOGNITION THAT CHANGE IN ITSELF CHANGE IN ITSELF IS DYNAMIC, AND IS DYNAMIC, AND EXISTS WITH US ...EXISTS WITH US ...

TO SEEK, TO FIND,TO SEEK, TO FIND,

TO STRIVE, TO FIGHTTO STRIVE, TO FIGHT

AND NEVER TO YIELD …AND NEVER TO YIELD …

TennysonTennyson

AS IN PAFAMSAS IN PAFAMS