1. Institute of International Medical Education Advisory Committee Meeting New York, June 22-23, 2000

2. PANAMERICAN FEDERATION OF ASSOCIATIONS OF MEDICAL SCHOOLS. PAFAMS An international challenge and opportunity for collaborative action in medical education and health

4. 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.

5. FEPAFEM FEDERACIONPANAMERICANA DE ASOCIACIONES DE FACULTADES [ESCUELAS] DE MEDICINA PANAMERICAN FEDERATION OF ASSOCIATIONS OF MEDICAL SCHOOLS PAFAMS OFFICE OF EDUCATIONAL RESOURCES OFFICE OF EDUCATIONAL RESOURCES

6. ORGANIZATION PAFAMS VICE-PRESIDENT PRESIDENT TREASURER Vocal North America Vocal North America Vocal South America Vocal South America Vocal Caribbean and Central America Vocal Caribbean and Central America Administrative Committee Executive Director l PAFAMS office of Educational Resources - Bogotá l PAFAMS office - Caracas l PAFAMS office of Educational Resources - Bogotá l PAFAMS office - Caracas

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

8. MEDICAL SCHOOLS affiliated 385 FACULTY ~>50,000 MEDICAL STUDENTS >500,000

9. CHRONOLOGY u Decision to create PAFAMS, Montevideo, 1960 u Created in Viña del Mar, Chile, in 1962 u The Council started operations in Poços de Caldas, Brasil, in 1964 u PAHO recognized PAFAMS as NGO 1965 u Headquarters in Bogota until 1976 u Office of Educational Resources in Bogota since 1977 u Headquarters transferred to Caracas 1977

10. ACTIVITIES 1968-1976 u Curriculum u Demography u International Courses on Health and Population u Continental Program on Information over Medical Education (PCIEM) u Program on Information & Documentation Centers on Medical Education and Health (CIDEMS)

11. ACTIVITIES 1977-1986 u Community Medicine u Development of Medical Education Standards (PRODEEM) u Analysis of Teaching / Service Integration (PROAIDA) u Family Medicine Program u Latin American Program for the Development of Odontological Education (PROLADEO)

12. ACTIVITIES 1992-1995 u Social Service and Community Program u Prospective Analysis of the Health of Women, Children and Adolescents u Communitary Social Service Program u Panamerican Program for the Development of Medical and Health Information (PANET)

13. ACTIVITIES 1995-1996-1997 u Information and Management System for the descentralization of the Venezuelan National Health System u Venezuelan Network of Health Information Data Bases: Medical Schools, Medical Libraries, Health Institutions. u Information and Documentation Center in Medical Education and Health (CIDEMS)

14. ·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 1 1 2 2 3 3 4 4 5 5

15. 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

16. 151,4839.21,860 151,4839.21,860 7 493.6 142 7 493.6 142 8 474.0 105 8 474.0 105 1001,7028.0 329 Established Economies Ex-Socialist Economies (Europe) LATINAMERICA WORLD Fuente: World Development Rtport 1993: Investing in Health/World Bank. Washington: WB., 1993 Region %WorldPopulationExpenditure (billions $) %PTB in Health per capita InvestmentU.S.$ INVESTMENTS & HEALTH EXPENDITURE

17. Venezuela: Health Budget in Real Terms (US$)

18. MD/10,000 Country19791990 Δ% Argentina26.726.8 0.4% Brazil 8.713.656.3% Colombia 5.110.9 113.7% Costa Rica 6.612.6 90.9% Chile 5.2 11111.5% México 8 17112.5% Panamá 8.516.4 92.9% Venezuela11.416.2 42.1%

19. Medical Schools in Latin America 1960 1992 196 418 Medical students 513,271 537,106 1985 1992

20. Relación Aspirantes/Admitidos 198012,01 198113,63 198211,14 198313,64 198413,55 198511,53 198610,21 1987 9,50 1988 8,71 1989 8,67 1990 9,69 1991 9,26 1992 9,29 1993 10,00 1994 9,01 1995 8,04 1996 7,59 1997 7,37 1998 6,90

21. Relación Aspirantes/Admitidos por Facultades Públicas y Privadas 1980-1998 198020,926,85 198124,127,19 198219,026,61 198321,518,09 198420,118,52 198517,317,80 198614,726,96 198714,815,62 198812,525,57 198912,575,64 199014,895,68 199116,114,96 199215,444,85 199316,455,09 199416,354,03 199513,484,22 199614,293,65 199714,963,12 199814,772,61 Año Públicas Privadas

22. CONFERENCIAS PANAMERICANAS DE EDUCACION MEDICA VII 1978 El Médico General Familiar New Orleans, EUA VIII 1980Estrategias para la Formación del Médico General Familiar Panamá IX 1982* Educación Médica Continua * Formación del Médico General o de Familia * Formación de Recursos Humanos para la Medicina del Año 2000 Buenos Aires X 1984Innovación y calidad de la Educación Médica Bogotá XI 1989Evaluación de la Educación Médica México

23. XII 1989Factores Críticos en Educación Médica Montreal, Canadá XIII XIV 1993Desarrollo de la Información de la Investigación Científica y de la Biotecnología y su Impacto en la Educación Médica Quito, Ecuador XV 1997La Educación Médica en el Tercer Milenio Buenos Aires CONFERENCIAS PANAMERICANAS DE EDUCACION MEDICA

24. Curriculum Seminars (1969-1972)Curriculum Seminars (1969-1972) Development of Standards in Medical Education (PRODEEM - PAHO ) (1979- 1981)Development of Standards in Medical Education (PRODEEM - PAHO ) (1979- 1981) Self-evaluation (1983-84)Self-evaluation (1983-84) Prospective Analisis (1985)Prospective Analisis (1985)

25. ACCREDITATION & EVALUATIONPROGRAMS ACCREDITATION & EVALUATION PROGRAMS 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)

26. 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- )

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

28. THE PRACTICE OF MEDICINE PROFESSIONAL ACTIVITY

29. MORAL COMMITMENT MORAL COMMITMENT SELF-REGULATION SELF-REGULATION INTELECTUAL AUTONOMY decision makingINTELECTUAL AUTONOMY decision making PROFESSIONALISM KNOWLEDGE KNOWLEDGE

30. CERTIFICATION FEPAFEM / FELAC legal vs. voluntary NATIONAL / REGIONAL Ministries of Education / Health National or Regional Boards UNIVERSITY Schools of Medicine Associations of Medical Schools PROFESSIONAL Specialists Societies

31. GENERAL SURGERY LATINAMERICAN FEDERATION OF SURGERY FELAC Committee on Surgical Education FORMAL TRAINING PROGRAMAS Residency : (2 years) 3 years 4 years CERTIFICATIONRECERTIFICATION

32. CERTIFICATION and ACCREDITATION in Latin America 2- PAFAMS Medical Schools 3- FELAC Professional surgical organizations IIME International Standards for Medical Education 1- PAHO Ministries of Health

33. CERTIFICATIONVERSUSACCREDITATION NATIONALPROVINCIALVERSUS INTERNATIONAL (common market) GOVERNMENT GOVERNMENT UNIVERSITY UNIVERSITY PROFESSIONAL PROFESSIONAL CENTRAL AMERICAN CENTRAL AMERICAN ANDEAN ANDEAN MERCOSUR MERCOSUR BILATERAL BILATERAL

34. CERTIFICATION and ACCREDITATION in 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

35. CERTIFICATION and ACCREDITATION in Latin America PAFAMS Panamerican Federation of Medical Schools PAHO Panamerican Health Organization Ministry of Education Council for Higher Education Council on Certification and Accreditation Ministry of Health Provintial Secretaries of Health CONGRESSIONAL ACTS VOLUNTARY

36. CERTIFICATION Purpose: To define and, through credentialing, implement requirements of education and standards of practice in the medical specialties

37. 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 ?

38. Number of specialists as % of total physicians LATIN AMERICA Chile Venezuela 50 – 75 % Belgium France Germany 25 – 50 %

39. too many specialists ?SPECIALISTPositive Negative 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

40. Even when specialists perform as general practitioners, there remains a trend to generate a greater number of examinations and procedures. Charles E. Lewis New Engl J Med 1969

41. S P E C I A L I S T Body of specialized knowledge intellectual capital Residency Graduate programs Accreditation WHO ? Certification Credentialing WHO ?

42. MEDICAL SPECIALTIES Which ? different recognition in different nations Example : Mastology Name of specialty Different meaning Example : Traumatologist Data & statistics inadequate

43. “Medical specialties seem to be a constantly expanding phenomenon in Latin America in the twentieth century.” Pan American Health Organization December, 1999 “The proliferation of specialties appears as a long-term trend.”

44. Medical specialties – credentialing (1996-99) Country No. specialties Credentialing Nature body Argentina 50 Ministry of HealthPublic Brazil 66Federal MedicalPublic CouncilPublic Chile 38 CONACEMNon Gvt. Colombia 40 ASCOFAMENon Gv.t Costa Rica 91 Assoc. Phys. SurgsProfess. assoc. Mexico 47Nat’l Acad. Med.Non Gvt. Panamá 53Techn. Council CouncilPublic Venezuela 45Venezuelan Med.Profess. Federationassoc

45. CREDENTIALING Argentina 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 )

46. CREDENTIALING Argentina Medical degree Residency Specialty certificate Re- certification UniversityUniversity, Specialty Societies, Ministry Secr. of Health, National Academy of Medicine Universities, financed by Ministry of Health Provincial Secretaries of Health National Academy of Medicine Colegio Médico Argentino

47. CREDENTIALING Brazil 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

48. CREDENTIALING Brazil November 24, 1995: National Education Council Interinstitutional Commission for Evaluation of Medical Education (CINAEM) EVALUATION

49. CREDENTIALING COLOMBIA Certification as specialist is a private and voluntary affair, and is done by ASCOFAME. Certification is issued upon completion o an approved graduate program by the Specialties Committee, which also defines minimum training requirements. Accreditation of programs is by the National Council on Higher Education ’s National Accreditation Council

50. CREDENTIALING COLOMBIA Congressional Bill No. 30, 1992 National Accreditation System National Accreditation Council Ministry of Education acts through selected academic peers

51. ASCOFAME Ministerio de Salud Pública RECURSOS HUMANOS PARA LA SALUD Y LA EDUCACION MEDICA EN COLOMBIA Conferencia Nacional de Resultados Agosto 9 de 1967 Ediciones Tercer Mundo ASOCIACION COLOMBIANA DE FACULTADES DE MEDICICNA

52. ASCOFAME RECURSO HUMANO EN MEDICINA: FORMACION, DISTRIBUCION Y BASES PARA UNA PROPUESTA POLITICA ASOCIACION COLOMBIANA DE FACULTADES DE MEDICINA 2000

53. ASCOFAME ASOCIACION COLOMBIANA DE FACULTADES DE MEDICINA SITUACION Y FUTURO DE LAS ESPECIALIDADES MEDICO-QUIRURGICAS EN COLOMBIA Documentos Varios Santafé de Bogotá, mayo de 2000

54. CREDENTIALING CHILE Autonomous National Corporation for the Medical 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 and issues corresponding Title

55. CREDENTIALING MEXICO Specialists Councils National Academy of Medicine National MedicalAssociation Interinstitutional Council on Human Resources for Health co-chaired by Ministers of Health and Education Accreditation: led by the Mexican Assoc. of Med. Schools National 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

56. uPERÚ: CONAFU, Council for the Accreditation of Medical Schools ASPEFAM, promotes the development of a National Accreditation System Governmental Council is in Charge.

57. uPANAMA: Ministry of Health: Creates National Council of Accreditation of Health Human Resources. uVENEZUELA: On going programs of the Venezuelan Ass. Of Medical Schools [ AVEFAM ] and the Venezuelan Medical Federation

58. 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

62. DESPROFESIONALIZACION BUROCRATIZACION CORPORATIZACION PROLETARIZACION “Managed Care” ATENCION MEDICA GERENCIADA MEDICINA = Interme - diación

63. DESPROFESIONALIZACION BUROCRATIZACION CORPORATIZACION PROLETARIZACION “Managed Care” ATENCION MEDICA GERENCIADA MEDICINA CIENCIA PROFESION

64. A U D I T O R I A necesaria Managed Care ATENCION MEDICA GERENCIADA MEDICO USUARIO

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

66. microscopio

67. INTERNET: Host Computers Growth

68. PAFAMS / Centernet on going survey: satellite access & capabilities (base  550) **  ** USA  * [+ 102 Academic Health Centers] D.R.  15  11  Answers  57 * + others on going *

69. ACTION LINES  MEMBERSHIP INTERLINK  ACCREDITATION  CURRICULUM INNOVATION  INFORMATION TECHNOLOGY  HEALTH & SOCIAL REFORMS  MANAGEMENT  ETHICS & VALUES

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

71. TO SEEK, TO FIND, TO STRIVE, TO FIGHT AND NEVER TO YIELD … Tennyson AS IN PAFAMS