by Cassandra Lobo, OPDES staff
This blog post is a summary of the Canadian Engagement in Physician Training Internationally webinar presented on November 12, 2020 by Global Health at Queen's.
Summary
- Goal of the Canadian Engagement in Physician Training Internationally:
Provide support for educational initiatives globally through holding a forum with a collection of medical educators, and health care experts.
- The group of experts discussed that being involved in post-graduate/higher education in less resource settings is one of the best ways that Canadian medical educators, and physicians can have the greatest impact on health outcomes.
- Presenters:
- Dean of the Faculty of Health Sciences, Queen’s University, Dr. Jane Philpott
- Chief Medical Officer & Executive Vice President Education, University Health Network, Dr. Brian Hodges
- Director of Global Health, Faculty of Health Sciences, Queen’s University, Dr. Nazik Hammad
- Executive Director (Interim) of the Office of International Collaboration, Royal College of Physicians, and Surgeons of Canada, Mr. Craig Ceppetelli
- Director, Practice & Systems Innovation, Vice-President Asia-Pacific, Royal College International, Dr. Susan Brien
- Outline of this forum
- Opening remarks by the Dean of the Faculty of Health Sciences, Queen’s University, Dr. Jane Philpott
- Discourses in Globalized Health Professions Education by Dr. Brian Hodges
- Queen’s Engagement in Medical Education Internationally by Dr. Nazik Hammad
- Ways to improve the postgraduate medical education in developing countries through the Royal College approachby Mr. Craig Ceppetelli
- Royal College International Projects, specifically the Simulation in Africa by Dr. Susan Brien
Opening Remarks
Dr. Jane Philpott has done work towards sustainable physician workforce around the world, more specifically in west Africa she worked as a clinician for a decade. Through her experience as a clinician, Dr. Philpott learnt that even though working directly with individuals, and families is beneficial, it may be more effective to be involved with education. Within the last three years, Dr. Philpott’s focus was on training health workers in Niger, West Africa, and identified individuals that could be trained as village health workers. As this approach allows individuals within the community to become experts on public health, and is more effective than bringing a team of experts from another country. This is the best outcomes for healthcare in rural areas of Niger.
The partnership between the University of Toronto, and Addis Ababa University started in the department of physiatry, and from here this partnership led to the creation of the psychiatry residency training program in Ethiopia. This partnership is known as TAAAC (Toronto Addis Ababa Academic Collaboration), and was formed in 2003 in order to develop sustainable postgraduate programs. In 2009, this partnership developed a curriculum to start the first family medicine program in Ethiopia. The faculty in leadership positions are Ethiopian, and have been trained in Ethiopia, making them the leaders of the future in family medicine.
Discourses in Globalized Health Professions Education
Dr. Hodges started his presentation with a thought-provoking question “Is it Westernization disguised as “better teaching” Guthrie (1980). This led to discussion of the discourses in globalized health professions education.
Dr. Hodges raised questions pertaining to who are the authors of our discourse, are they economists, health professionals, or political figures?
Queen’s university is very keen on working collaboratively in order to observe the role of Canadian health care practitioners, and how Canadians can voice their perspectives on Canada’s impact, and footprint on the world. One of the best ways to design public institutions internationally is through collaborating/contributing towards higher education, and focus on being an educator, researcher or those assisting with long term impacts of the health workforce rather than focusing on daily clinical work.
In 2009 to 2010, there was little data and framework to assist higher educations with whether or not their work was helping/advancing countries, and international relations. The sole focus was on the revenue generation or economic standpoint instead of globalization. The emphasis on the “cheerleader” discourse was strong, and sometimes led to ambiguity/obscurity on their work.
In 2011, a globalization research group started, and the Dean of Medicine at the University of Toronto, Dr. Catherine Whiteside stated that more engagement is needed, and said that “As the world indeed becomes flatter, the demand for greater engagement within and outside our complex network of diverse communities grows”. The first statement “As the world indeed becomes flatter” is a reference to a work by Thomas Friedman, titled “The World is Flat”. This statement suggests that on one side there is a continuous global integration process, but on the other side the assumption that opportunities increase as the globalization progresses, and low-income countries develop.
It seems that there is a further emphasis on the economic lens, more specifically medical schools wanting to generate more revenue. This was uncommon in the medical education, more common in the business/economics sector. The Australian writers, Slaughter & Leslie, stated that the academic capitalism is gaining more importance since many countries are decreasing government funding for higher education. Dr. Hodges noted that when he attended medical school at Queen’s University, the domestic tuition was only $,2000. Today it the tuition has reached upwards of $20,000, which suggests that the increase in tuition is much more than inflation. Universities realised that domestic tuition was not enough and needed to find other sources of revenue. Furthermore, Jamieson conducted a study on the phenomenon that for-profit medical schools have currently outnumbered publicly funded medical schools around the globe, for-profit medical school has not reached Canada as of now.
The “Importing” students for training and “re-export” was not constructed on a tuition basis, rather on a bilateral relationship between countries, hence why there is sliding scale in which students can receive from free tuition to up to $100,000 per year. These bilateral relationships/international partnerships have been created between many colleges, and universities for sole purpose of strengthening their economic health.
Another source of revenue that higher education has started are the “off-shoring” medical school, an example of this is the Weill Cornell Medical College in Qatar, which is the first off-shored medical school. The Cornell University stated that: “Although we [Cornell] are the first, we won’t be the last medical school to do this…Our school has been in the black for nine straight year, but we can’t afford to lose money (with the international school)” in 2001. Many thought this was very precariousness, as there are many risks, and ambiguity involved with building an offshore medical school.
A colleague of Dr. Hodges, Robert Paul published a thesis for his PhD the 100 years of academic medicine in Canada “How Michael Porter become the new Abraham Flexner”. Paul calling Michael Porter the new Abraham Flexner, who was the “founder” of the medical education of the last century. Michael Porter is an economist who wrote models of revenue generation in the new century along with Harvard University. Paul’s thesis examined Canadian universities, and academic hospitals, and how they everything is connected in a full circle.
In total there are three risks involved with the revenue streams that higher education/post-secondary education are using. The risks include brain drain, cultural homogenization, and the absence of regard, comprehension, and/or respect for traditional culture.
The first risk, brain drain is prevalent in the importing of students for training. Some countries require students to return to the country after the training is completed or known as return of service, whereas others do not. Countries such as Kuwait, and Saudi Arabi have a return of service, this means that after students have completed their training, for example in Canada, they need to return, and work in these countries. However, Ethiopia does not have a return of service, hence student complete their post-graduate training abroad, and never return. This contributes to brain drain away from Ethiopia, and is more prevalent in lower-income countries. The second risk is cultural homogenization, which is involved in the exporting of accreditation, curriculum, and exams. The selling of accreditation, curriculum, and exams raises questions of whether the institution buying them are public or private, as if the institution is private, it can be less visible internationally. The third risk is the absence of regard, comprehension, and/or respect for traditional culture. When exporting/sending teachers abroad, it is important that their teachings/approach to teaching does not replicate, and resemble colonialization. It is significant that the teachers’ approach is in a thoughtful manner, and does not disrespect the traditional culture.
The coronavirus pandemic this year questioned globalization. Since the virus started, some political figures have undermined globalization, or wanting to place barrier to oppose it. The headlines over the news such as “Universities will not be the same” highlights that the economic loss that universities face during this pandemic. However, on a positive note this is an opportunity to restart, and reassess.
Queen’s Engagement in Medical Education Internationally
The response to Global Health Mandates is separated into WHO (World Health Organisation) Global Milestone 2030, and SDG (Sustainable Development Goals) 3: Health target. Dr Hammad emphasized the importance of healthcare workers, as without these workers health systems cannot function. It is important to note that equitable access to health workers is used rather than using the term “shortage”. The WHO Global Milestone 2030 aims to halve the inequalities of access to healthcare workers in all countries. Their goal is to increase universal accessibility, acceptability, quality and coverage.
At Queen’s University, the focus of the engagement in global HPE is on educational scholarship, faculty, and program development, knowledge sharing, and generation. An example of the program development is developing the first medical oncology program in West Africa, within the University of Nairobi. Other partnerships include the Rwanda Anesthesiology, Department of radiology partnership with the University of Nairobi, Surgical Oncology Fellowship with WACs, and etc. Dr. Hammad also compared local faculty in LMIC with Faculty from High-Income Countries, and also covered the concept of brain drain prevalent in this discipline. In addition, ways in which shared global learning can address the internal brain drain including local training, providing support for local teachers, and mentorship.
Ways to improve the postgraduate medical education in developing countries through the Royal College approach
The Royal College of Physicians, and Surgeons of Canada is a not-for-profit organization, and registered charity that was started more than 90 years ago in Canada. The RCI (Royal College Canada International) is charitable, and non-profit organization, which is actively working in approximately 35 countries around the world through academic collaboration, consolation, engagement, and international development aid.
The IDAC (International Development, Aid, and Collaboration) started in 2018. Before 2017, projects in Niger, Nepal, and Haiti in order to enhance the medical education system, and was received with mixed reactions. In 2019, RIC worked with Queen’s university, and the Canadian anesthesiologist society to create two pilot programs with Haramaya University, Rwanda University, and Dalhousie university in Rwanda, and Ethiopia program. The Ethiopia program focused on improving the training environment in four specialties, and the duration of this program is three years. The Rwanda project is a retrospective view on the radiology program, and provided a roadmap/plan for the next two to three years. There was success in both programs, and this led to the development of the IDAC program.
In 2019, applications for the IDAC program was sent out, and received 61 applications. There was a total of 11 programs but were unfortunately postponed from April to September/October due to the coronavirus pandemic. IDAC is currently supporting 71 fellows of the Royal College in their ventures abroad, and this IDAC hopes to increase projects to 20 in the following year. In September of 2021, IDAC hopes to increase the number of applicants through an amended/revised process in order to provide transparency, and fairness. For this year, applicants were narrowed from 61 to only 9 projects. The typical duration of projects is between one to three years, however if there is a merit/business case, the project can last longer than three years. The funds collected for these programs through cash contributions are more than $30.000 per year.
IDAC focused, and is currently focusing on “standing up” in order to support fellows. There are challenges that IDAC is facing such as considering the unintended consequences of their good efforts, and the importance of the 3Ps; persistence, presence, and patience.
Royal College International Projects, specifically the Simulation in Africa
Dr. Brien, and Dr. Bhanji are part of the Royal College, and are collaborating with WACS (Western African College of Surgeons). WACS is a multinational college, that consists of surgeons from 18 various countries in the region of West Africa. The goal of WACs is to advance, and organise PGM training, certification in surgery, and other specialties, such as anesthesia, radiology, ophthalmology, and etc. WACS aims to continue to be creative, as well as improve the gap in healthcare professionals. However, WACS experienced failures in clinical care, and audited the program of general surgery as they had to lower the pass rate below 50%. Over two decades ago, WACS had a program for a diploma in surgery even though there was a lot of internal controversy with their own members. Hence, this allowed physicians to be trained, and certified based on the essential surgical services, and training time was shortened.
The Royal College needed to address how to improve the performance of candidates in their fellowship exams, and advance the global surgery mandate. WACS started simulation centers in 2018 to rectify the problem, and the Royal College’s role was support. This support included creating teaching capacity, and improving exam delivery. These simulation centers caused challenges such as the absence of research, and scholarship, sole focus on one skill, poor education design, and etc. The Royal College helped in creating a simulation capacity through forming a set of standards, conducting research on grants, and etc.