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Embracing Medical Education’s Global Mission

Farmer, Paul E. MD, PhD; Rhatigan, Joseph J. MD

doi: 10.1097/ACM.0000000000001433
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Shortages of trained health care workers plague low- and middle-income countries around the world. When resources are scarce, the ability to support medical education is severely constrained. While there are many important “building blocks” of health systems that need to be bolstered in low- and middle-income countries, the authors propose that U.S. academic medicine can make unique contributions in the realm of human resource development—specifically, increasing the supply of physicians who directly provide health care to the populations they serve and who often manage and lead these health systems. Strengthening medical education in low- and middle-income countries is critical to improving the quantity and quality of physicians to staff and lead these health systems. The authors provide specific examples of how U.S. institutions are pursuing this global endeavor, including the Academic Partnership Providing Access to Healthcare in Kenya, the Medical Education Partnership Initiative throughout Africa, partnerships between U.S. medical schools and with institutions in Qatar and Singapore, and postgraduate medical education efforts in Vietnam and Haiti. They urge that the U.S. academic medicine community embrace this challenge as part of its mission to ensure that all those who, wherever they may live, have the ability, the dedication, and the compassion to pursue a career in medicine be given the opportunity to do so.

P.E. Farmer is Kolokotrones University Professor of Global Health and Social Medicine, Harvard University, chair, Department of Global Health and Social Medicine, Harvard Medical School, and chief, Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts.

J.J. Rhatigan is associate professor, Harvard Medical School, and associate chief, Division of Global Health Equity, Brigham and Women’s Hospital, Boston, Massachusetts.

To read other New Conversations pieces and to contribute, browse the New Conversations collection on the journal’s Web site (http://journals.lww.com/academicmedicine/pages/collectiondetails.aspx?TopicalCollectionId=53), follow the discussion on AM Rounds (academicmedicineblog.org) and Twitter (@AcadMedJournal using #AcMedConversations), and submit manuscripts using the article type “New Conversations” (see Dr. Sklar’s and Dr. Weinstein’s May 2016 editorials for submission instructions and for more information about this feature).

Funding/Support: None reported.

Other disclosures: P.E. Farmer and J.J. Rhatigan are both affiliated with Partners In Health.

Ethical approval: Reported as not applicable.

Correspondence should be addressed to Joseph Rhatigan, Brigham and Women’s Hospital Division of Global Health Equity, 75 Francis St., Boston, MA 02115; telephone: (617) 521-3337; e-mail: jrhatigan@partners.org.

Editor’s Note: This New Conversations contribution is part of the journal’s ongoing conversation on global health professions education—how ideas, experiences, approaches, and even resources can be shared across borders and across cultures to advance health professions education around the globe.

Health systems in many low- and middle-income countries are chronically crippled by shortages of trained health workers,1 and physician shortages are particularly difficult to address because of the large investments and long timelines needed to train physicians. In 2010, the Lancet Commission’s landmark report “Health Professionals for a New Century” was blunt in its assessment of the state of global medical education, stating that, worldwide, “the distribution of medical schools does not correspond well to either country population size or national disease burden.”2 One continent is especially burdened by training shortfalls: “31 countries have no medical school whatsoever, nine of which are in sub-Saharan Africa; 44 countries have only one medical school, 17 of which are in sub-Saharan Africa.”2 Not surprisingly, all of these countries face shortages of physicians and other health professionals.

For low- and middle-income countries that face chronically underresourced health systems, the ability to allocate resources to medical education is severely constrained. In addition, these systems often suffer from chronic shortages of medications, supplies, facilities, and management systems that present similarly pressing needs for investment. To put this in perspective, each year the United States currently spends around $9,000 on health per capita while many nations in sub-Saharan Africa and several in southeast Asia spend less than $100 per capita.3 In these nations, funding for medical and nursing education competes with spending for other essential elements of the health system that are also in short supply.

While there are many important “building blocks” of health systems that need to be bolstered in low- and middle-income countries, we wish to focus on one where U.S. academic medicine can make unique contributions—namely, human resources: the physicians, nurses, and allied health professionals who directly provide health care to the populations they serve and who often manage and lead these health systems. Strengthening medical education in low- and middle-income countries is critical to improving the quantity and quality of physicians to staff and lead these health systems. For the purposes of our audience, we focus here on training physicians, but similar arguments apply to nursing education, pharmacy education, health manager training, and a host of allied health professional education. We particularly want to emphasize the key role of nurses as providers and leaders who are critically in short supply in low-income nations.

Although the U.S. academic medical community often feels squeezed by increasing demands and decreasing resources, we are swimming in abundance compared with the vast majority of the world: an abundance not only of funding, but of institutions, educational systems, knowledge, and personnel. U.S. medical schools are universally dedicated to the principle that the profession of medicine should be open to all who have the ability and willingness to undertake the long, difficult road of study, practice, and adherence to the professional values that bind us to our colleagues across generations. We must also look beyond the walls of our schools and our borders to where the need for our expertise in education is the greatest. If U.S. medical schools are to remain relevant in a world where technological and social changes are rapidly transforming our profession, we need to embrace our roles as global citizens and make the advancement of medical education worldwide a core tenet of our overall missions. As our world grows smaller, we can no longer limit our mission as training only those who by an accident of birth or circumstance are able to apply to our schools.

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U.S. Academic Medicine’s Global Engagements

Many U.S. medical schools—too many to describe here—have already answered this call and are engaged in global medical education abroad. The following brief overview serves to highlight some innovative models. In undergraduate medical education, the partnership between the consortium of U.S. medical schools led by the University of Indiana Medical School and Kenya’s Moi University School of Medicine has not only seen a robust bidirectional exchange of faculty, medical students, and residents between the United States and Kenya, it has also resulted in the creation of an important health care delivery organization, the Academic Partnership Providing Access to Healthcare (AMPATH). While this organization began as an AIDS treatment program, AMPATH now also provides primary health care and additional health services in collaboration with the Government of Kenya to a population of 3.5 million people in western Kenya.4

From 2010 to 2015, the Medical Education Partnership Initiative helped catalyze a network of African and U.S. medical school collaborations that was highly successful in strengthening medical education in Africa.5,6 Funded by the U.S. President’s Emergency Plan for AIDS Relief (PEPFAR) and the National Institutes of Health, this initiative invested directly in African medical schools to improve the quality and quantity of graduates, retain physicians in the workforce, and increase research capacity. Despite its well-documented successes and uniform praise, the initiative’s funding is uncertain moving forward. We hope resources can be mobilized to revive its work, as strong academic medical institutions in Africa are critical to improving the health systems there. Failure to nourish these medical schools will predictably lead to a decrease in their capacity to train the next generation of local physicians and to generate new knowledge about pressing local health issues.

The successes of Weill Cornell Medicine’s campus in Qatar7 and Duke University School of Medicine’s in Singapore8 provide another model of how U.S. medical schools can partner with institutions abroad to create high-quality medical education programs that provide an essential source of physicians for their respective countries.

In postgraduate medical education, PEPFAR and the U.S. Agency for International Development (USAID) have supported the Rwanda Human Resources for Health Program, an innovative program that is a template for others currently proposed. This seven-year-long program, launched in 2012, focuses on the creation of new residency, nursing specialty, and health management programs in Rwanda. The program deploys approximately 100 U.S. medical faculty a year from a consortium of 23 U.S. academic medical centers and schools to Rwanda to serve as mentors to Rwandan faculty who are building new postgraduate residency programs.9 Over half the U.S. faculty spend more than six months a year in Rwanda, while the rest, often subspecialists, have shorter engagements. Faculty are given partial salary support and a stipend toward travel and living expenses through a grant from PEPFAR and USAID.

Other notable efforts in postgraduate medical education are the Partnership for Health Advancement in Vietnam (HAIVN)10 and the Hôpital Universitaire de Mirebalais (HUM)11 in Haiti. HAIVN is a collaboration between Harvard Medical School and two affiliated Harvard teaching hospitals, and the Vietnam Ministry of Health (MOH) and two prominent Vietnamese medical schools. This collaboration is supported by grants from the U.S. Centers for Disease Control and Prevention. HAIVN began as an effort to improve HIV care in Vietnam and has now made strengthening medical education through curriculum innovation and faculty development a priority focus. In addition to engagement with local medical schools, HAIVN works to support the Vietnam MOH to develop systems of accreditation and licensing in medical education. In Haiti, HUM was built by a nongovernmental organization, Partners In Health (which both authors are affiliated with) and the Haitian MOH in response to the destruction of the national teaching hospital in the 2010 earthquake. HUM has engaged faculty members from Harvard Medical School to create a number of residency programs including internal medicine, general surgery, pediatrics, obstetrics–gynecology, and the only emergency medicine residency program in the country. All these programs are led by Haitian physicians, some of whom have returned to work in Haiti after careers in the United States and Europe.

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Increasing Medical Student Supply and Retaining Physicians

As the community of U.S. medical educators considers the challenges of strengthening medical education globally, we also need to consider both the supply of well-prepared premedical students as well as the retention of practicing physicians and faculty. The challenges of improving secondary school education in low- and middle-income countries are manifold, but this bottleneck must be acknowledged and addressed if efforts to improve medical education systems will benefit more than those affluent enough to obtain a decent high school education. This is a lesson we are learning in the United States, as a recent report by the Association of American Medical Colleges (AAMC) traces the underrepresentation of black men among medical school applicants to challenges they face in obtaining a good public school education.12

To retain physicians and faculty in these nations, these physicians need opportunities to practice within systems that allow them to provide the care they are taught to deliver. Efforts to improve medical education have the synergistic effect of both training more and better-qualified physicians and providing opportunities for practicing physicians to engage in teaching. This engagement has the potential to increase physician satisfaction and to disseminate the most up-to-date practices.

Another important step is to ensure that we in the United States train enough doctors for our own needs to reduce the number of physicians we import from other countries, many of which have critical physician shortages. Many international medical graduates’ (IMGs’) medical educations are heavily subsidized by their home countries. Alarms about a U.S. physician shortage going back over a decade13 have been slow to be addressed, and a recent report by the AAMC documents the severity of the impending shortage’s likely impact on the U.S. health care system.14 Physician immigration to the United States, made possible by the large gap between the number of U.S. medical graduates and the number of first-year residency positions, drains both financial investments and human resources from IMGs’ home countries. Thanks to leadership by the AAMC and others over the past 10 years, there has been an expansion in graduates of U.S. medical schools as new schools have opened while others have increased their class sizes. Although this has closed the gap between the U.S. health system’s need for first-year residents and the supply of U.S. medical school graduates, this gap still exists and will likely remain based on expert projections.15

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Universal Access to Medical Education

U.S. medical schools have a great deal to gain in embracing this global educational mission. Our students and trainees are clamoring for us to do so, and we would be wise to harness that passion. In addition to the energy and renewed purpose these collaborations inject into traditional institutions comes an opportunity to pursue myriad educational research questions both particular to medical education as well as to the science of learning in general. The results of this research can immediately be turned into practice. Educational innovation in U.S. medical schools is slow and takes place over long cycles of curriculum reform, limiting the lessons that can be drawn from such work. The creation of new medical schools abroad and strengthening of existing ones provide opportunities to put the most up-to-date evidence about learning into practice and to iteratively perfect these methods rapidly. Once we as a global educational community learn the best ways to teach and develop the most effective curriculum tools, these can be shared broadly as global public goods.

Should not all people, no matter where they happen to live, have access to someone well trained in our profession? The U.S. academic medical community can make this aspiration a reality by embracing global medical education as a core principle of its mission. The gates of our profession should be open to all those who, wherever they may live, have the ability, the dedication, and the compassion to pursue medicine’s sacred mission.

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References

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© 2016 by the Association of American Medical Colleges