Kanter, Steven L. MD
There are a growing number of collaborations between medical schools in different countries. For example, an established medical school with a proven record of educational innovation in one country may provide expertise, guidance, curricular materials, or other kinds of support to a university in another country that is developing a new medical school or reforming an existing one. Or a research-intensive medical school in one country may help launch a research effort in a country in which there has been little biomedical investigation.
As I listen to faculty members and students who become involved with these initiatives, I hear both enthusiasm and skepticism, both passion and ambivalence.
Some engage in these initiatives with the conviction that partnering with other institutions is clearly the right thing to do. If there is an opportunity to help another country that is working hard to improve its system of educating physicians and discovering new knowledge, what could be a more noble deed? On the other hand, I also hear some individuals wonder “Why would we provide knowledge and know-how to those who will then compete with us?”
This range of reactions to international collaboration inevitably evokes the question, What are the benefits and risks of engaging in such relationships?
Certainly, there are a number of potential benefits to individuals, medical schools, society, and the world. First, there are humanitarian reasons to collaborate. A commitment to improving the education of physicians and scientists can contribute to the welfare of a population.
Second, collaboration can be beneficial to the health of all. Individuals who have access to better medical care usually are healthier. And physicians and other caregivers who have access to the latest knowledge in biomedical science are better equipped to deal with individual health problems as well as public health threats. Since disease respects neither national boundaries nor government mandates, a better-educated, well-trained cadre of physicians and scientists in a particular country can be more effective in preventing the spread of disease to other parts of the world.
Third, collaboration requires learning more about wellness and illness in other cultures. This informs and enriches our understanding of the practice of medicine and provides a basis for important new questions in biomedical science. Also, it helps us develop a sense of the full range of values, mores, and practices related to health and illness.
Fourth, there are educational benefits. Each partner school can offer to its students, residents, and faculty new learning opportunities in the other school's country.
Fifth, collaboration can be of financial benefit to one or both partners.
Sixth, collaboration can enhance the reputation of one or both partners. For example, a school may benefit from being seen as innovative in global health education, while another school may be seen as progressive by associating with a well-known institution. A better reputation can enable a school to recruit more competitive faculty, residents, and students.
Seventh, having a trained health care workforce in a particular region or country is less costly and more effective than receiving health care workers from other countries sporadically and for limited periods of time. In addition, as Clinton and colleagues point out in this issue of the journal, training individuals in their home country may improve retention of health care workers in that country.1 This has the potential to stem the brain drain and lead to long-term economic benefits.
And finally, collaborations can be motivating to individuals who enjoy learning about medicine in a new context, exploring other lands, and learning new languages. Many would agree that travel broadens the mind and enables faculty and students to bring new ideas back to their home institutions.
Of course, there also are risks in an international relationship between medical schools. For example, devoting time to a collaboration has the potential to distract a school from attending adequately to local needs and concerns. It is critically important to develop sound ways of estimating time commitments and costs, including opportunity costs.
Another risk is “training the competition.” As I mentioned above, I have heard some contend that, by providing knowledge and know-how to another institution, the “giving” institution makes itself less competitive while rendering the “receiving” institution more competitive. Although this is a valid theoretical concern, I am not convinced that it is a real threat. Knowledge moves around the globe so fast, especially in today's smaller world,2 that it can be time-consuming and expensive to control access to it. An institution's scarce resources are better spent on creative and innovative approaches to developing new knowledge than on security and protection of existing knowledge, which, very quickly, will become out of date.
And, in thinking about competition, it is important to consider what one is competing for. Is it economic advantage or better health for all?
Other risks include the fact that collaborations could fail. One or both partners could be worse off financially than they were before they entered into a relationship, and both could suffer diminished morale, which could discourage interest in future opportunities to collaborate. Also, cross-cultural misunderstandings (which can occur if both parties have not done their homework to minimize such misunderstandings) can weaken or even doom a collaboration.
There also are risks inherent in working in dangerous or politically unstable parts of the world and, of course, schools may need to deal with unexpected disasters. In this issue of the journal, Steiner and colleagues describe, in the context of global health electives, three such crises, which are relevant to international collaborations as well.3
I expect that in the future, we will see both a greater variety and an increased number of collaborations between medical schools in different countries. And, given the benefits and risks, my own sense is that there is much to be gained. This means, of course, that it is more important than ever before to develop a comprehensive, keen, and robust assessment of the benefits and risks, so that all parties can engage in informed collaborations with the greatest chance to succeed. And if we do succeed, the opportunity to improve our understanding of medical education, biomedical science, and the human condition could benefit the whole world.
Steven L. Kanter, MD