The position of mentor did not exist at this time, and the ratio of IM specialists to residents was 1:9. Daily supervision of the residents’ clinical work was done by the few specialists working in the department at the rate of one specialist to three residents. Each of the residents had seen a mean number of 12 beds. The mean amount of contact between the “supervisor” and the resident was less than one hour per week. Each week, one resident presented at the single IM teaching conference. Supervised medical rounds occurred two days per week because the supervisors had their own clinical duties (such as outpatient clinic, visits, and specialized exams) on the other days. All residents had extra jobs consisting of emergency room duty, and 15 residents worked a night shift in private clinics at least once a week.
Although writing research proposals and manuscripts was perceived as a requirement for specialist graduation research by all residents, only 3 residents were involved in this process. No line item existed in the NCPS budget to support the research activities of residents or specialists. Records indicated that 12 of the 21 residents currently in the program had completed their in-country training. Ten of the current residents had been in the program a mean of nine years and were waiting for financial resources to complete their out-of-country training requirements. In addition to having no dedicated clinical teaching faculty, the IM department had no medical library or Internet connectivity, and there were no tablet computers or laptops available for the residents.
After the needs assessment phase, we held formal meetings with the various stakeholders to present the preliminary results. A coordinating team including specialists from the IM department, MCH, and MMC was created under MEPI leadership. Between July 2011 and December 2011, this team worked to define the detailed interventions and reported to the NCPS and MOH every three months to ensure that the principles of these interventions were shared by all stakeholders and would be sustainable. We selected five areas for intervention: curricular; learning environment; faculty development; building capacity for research; and financial compensation (Table 2).
Program structure and curriculum design
The coordinating team redesigned a competency-based curriculum that contained detailed descriptions of the learning objectives, core educational activities, an evaluation system, graduation requirements, and timelines. Core MEPI faculty delivered additional structured teaching activities, and several short courses focused on diagnostic technologies or commonly encountered clinical syndromes. Weekly teleconferences between the IM department and UCSD were held, during which residents interacted with experts from Mozambique and filled in charts created for recording key activities and for supervisor evaluation. Workshops were organized on presentation of clinical cases, competency-based learning, evaluation methods, and ethics in medical education. The residency exchange program between UEM and UCSD, started in 2009, was enhanced to allow a three-month training experience at UCSD, concentrating on clinical areas where expertise is not available in Mozambique. Point-of-care technology, particularly the use of bedside ultrasound by residents to help manage common conditions in the wards, was formally introduced.
Learning environment improvement
Residency training activities that had been limited exclusively to mornings were extended to the afternoons. These included supervised patient care, transferable skills courses, bidirectional teleconferences for case discussion with residents from UCSD, and teaching seminars delivered by UEM-FoM specialist faculty members. Medical grand rounds, additional clinical seminars, and a monthly clinic–pathological session were also introduced, the latter focusing on cases of death in which autopsies had been performed and analyses of data on causes of admission and mortality in the department.
Wireless Internet connectivity was established in the MCH IM department, and iPods and iPads were made available for residents and faculty for bedside use. Clinical applications, such as UpToDate and PubMed, were installed, allowing access to online and offline references. Dedicated computer terminals were also provided in study rooms adjacent to the medical wards; these access points within the MCH and UEM-FoM greatly expanded access to medical information, including HINARI and Elsevier’s medical textbook collection.8
Three IM specialists (having less than one year of specialty) and eight residents in their last year of training were competitively selected to help support the UEM-FoM faculty. These individuals were designated “firm chiefs” and were tasked with supervising routine residency training activities, including organization of morning conferences, early medical rounds with younger residents, afternoon activities, assisting the reporting on the statistics of the department, and organizing clinical case discussions. They were allowed additional time to enhance their own training in medical education; two senior specialists from UEM and UCSD mentored each firm chief in educational and research activities.
Didactic courses in research methods, grants and manuscript writing, and human research subject protection were formally integrated into the residency training program to provide faculty and residents with additional competencies for research. In addition, monthly sessions were established for residents, faculty, and investigators to present and discuss research proposals and improve their research proficiency.8
MEPI has provided salary supplements to specialist faculty and firm chiefs involved in bedside training and research to encourage their engagement in teaching. The payments, corresponding to approximately 25% of a specialist’s salary, were added as a bonus, and through negotiation with the MOH, so that the government can continue the support after the MEPI grant ends.
One particular characteristic of the Mozambican IMRP is the fact that it is supervised by NCPS, which is composed of members of the MMC and the MOH, rather than being overseen by the university. This accounts for the absence of dedicated clinical teaching faculty. These half-time faculty also have clinical care duties, and each supervises an average of nine residents. As a consequence, they are often overworked, with little time or energy for residents. This environment reduces the motivation to learn, with residents often left having 25 hours or more a week for unsupervised activities.
The scheduled five-year IMRP term had been rarely respected, as demonstrated by the number of residents taking nearly twice that time to complete training. Prolonged time in the program, minimal teaching, limited diagnostic and therapeutic options, and lack of resources within MCH have negatively affected the training environment and the ability to attract residency candidates. As enrollment in the IMRP lagged, workloads increased and training quality declined further.
The MEPI innovations have directly addressed many of these problems. At the start of the MEPI program, the IM department had neither a medical library nor Internet connectivity, and digital access to medical and scientific information was not readily available. Few residents had access to a tablet or laptop computer, and those who did had little knowledge about how to obtain relevant medical information. Communication among staff from different clinical services was limited because of this lack of electronic connectivity, which made it difficult for staff to obtain diagnostic testing results or share patient information. In the past three years, we have restructured the training program, improved communications, increased access to digital reference materials, and improved support for research and teaching. The introduction of point-of-care imaging techniques and access to medical information on tablet computers to support clinical diagnoses in real time deserve special attention because of their potential to motivate residents to enroll in residency programs.9 The impact of point-of-care ultrasound has been reported from similar settings in rural Rwanda.10 IM specialists can likely be trained to become proficient in ultrasound during their residency programs. Because this durable and portable tool is becoming more affordable, it also has great potential for training, patient care, and research in developing countries.
Role modeling and research training have changed the environment of the residency program. Visits to the UCSD gave Mozambican residents opportunities to observe medical educational approaches that might be adapted to their own training. These included evidence-based learning, structured didactic conferences, clinical and translational research, case-based learning, and peer-to-peer teaching. Integration of visiting UCSD residents into postgraduate teaching activities at MCH also helped reinforce medical education concepts that are used in developed settings. Despite specialist graduation requirements, there had been no structure to mentor residents in research methodology, proposals, or manuscript writing. The introduction of research training has increased interest in research, both among trainees and faculty, and is likely to contribute to the sustainability of teaching institutions.8
The most concrete evidence of the impact of the MEPI initiatives is the simultaneous steady increase in the number of candidates applying for and being accepted into the IMRP; the number of residents in the IM department has increased from an average of 10 per year prior to MEPI to 30, 49, and 75 in 2010, 2011, and 2012, respectively.
Increased availability and engagement of the local faculty, teleconferencing with faculty from abroad, and increased mentorship8 may have played a role in the dramatic increase in the number of residency candidates. However, possible confounders include having outside support from “the West” or having outsiders involved at all. These and other factors may become apparent once the program becomes independent and is managed locally. The outcomes of medical education innovations are not readily assessed in the short term. A program of monitoring and evaluation extending into the future will be important in identifying the successes of the program and the factors responsible for those positive outcomes.
Our findings suggest that expanding IMRP has influenced postgraduate medical educational in Mozambique, with other specialty training programs beginning to incorporate some of the strategies used in IM. The contribution of UCSD through mentoring UEM faculty, assisting with laboratory improvements, and providing expertise in clinical and translational research and IT systems has reduced the need for international training, thereby mitigating the risk of “brain drain” to high-income countries.3 These interventions have increased the quality of training and medical care and, likely, will improve the reputation of the teaching hospital, which will help its sustainability and improve its appeal to residents.
By intensifying and structuring training activities, this model may reduce the length of IM training, allowing for an increase in the output of specialists, many of whom may become faculty. More efficient use of the limited number of faculty and residents can be achieved through organizational realignments. Partnerships between academic centers in developed and developing countries may contribute to improvements in postgraduate medical education and to improved health care in developing countries in significant and sustainable ways.
Acknowledgments: A.O.M. developed the questionnaires, supervised data collection, and wrote the draft manuscript. E.V.N., C.C., R.B., and R.S. contributed to the conceptualization of the project, participated in data collection, implemented the data analysis plan, and reviewed and edited the draft manuscript. C.B., M.P., C.F., S.P., P.L., and W.T. participated in focus group discussions and meetings with key players, faculty, and residents and reviewed and edited draft manuscripts. A.N. contributed with content and editing of the manuscript. E.A.S. coformulated and coimplemented the bioinformatics strategy and reviewed and edited the manuscript. All authors read and approved the final manuscript.
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© 2014 by the Association of American Medical Colleges
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