Back from Africa

Accompanying the August issue is a supplement devoted to a collaboration between US and African medical schools, known as the Medical Education Partnership Initiative (MEPI). I attended a conference in Maputo, Mozambique earlier this month at which many of these authors presented their work and discussed the next steps in the collaboration. Little did we know when planning the conference that the Ebola outbreak in West Africa would bring new urgency and relevance to the need for an educated workforce of physicians, nurses, medical assistants, and public health experts not only to address African health care needs but also to provide the expertise to prevent the spread of the disease to other countries. The unexpected introduction of an untested medication that was administered to two Americans with dramatic effect also raised questions about ethics, communication, and trust that could have disrupted our planned discussions. To the great credit of the MEPI collaborators, their four years of commitment to relationship building overcame any temporary uncertainty and provided a basis for renewed commitment to work together in the future. I would like to share a few themes from the conference that I believe are particularly relevant to US medical education.

 

MEPI Conference

(from left to right) James Tumwine, editor of African Health Sciences (Uganda); David Sklar, editor of Academic Medicine; Fitzhugh Mullan (MEPI coordinating center PI); Zoe Mullan, editor of Lancet Global Health; Roger Glass, director of the Fogarty International Center at NIH; and James Hakim, incoming chair of the PI Council of the 13 MEPI schools (Zimbabwe)

African medical students have frequently left their homes to pursue education and work in other more developed countries, and they often do not return to Africa. The conference attendees first discussed the need to develop residency programs that would provide in-country graduate medical education for medical school graduates, particularly in primary care. Mocumbi et al describe how internal medicine residency training developed and grew through collaboration with faculty from the University of California San Diego. [1] Beyond residency, what will physicians need to successfully practice in a rural hospital? What infrastructure will support the iPads and computers that now carry the information physicians need? What skills will physicians need to lead teams of nurses and medical assistants? What financial support will physicians and their families need to create a safe and fulfilling life in the community? As I heard the conversations about these issues, I realized that many of the questions are relevant to medical education in rural and underserved parts of the United States. Indeed one MEPI collaboration includes the implementation in Kenya of a rural education program based upon the University of Washington’s WWAMI program. [2]

In an environment in which the disease burden is high and the number of trained physicians is low, what are the options for delegating certain parts of the traditional physician’s skill set to non-physician providers? At the conference, we discussed how individuals without medical degrees could be trained to perform C-sections and emergency trauma surgery to serve isolated rural areas, with outcomes comparable to those of trained surgeons. This discussion reminded me of conversations we are currently having in the U.S. about nurse practitioners and physician assistants and the roles they could play in meeting projected physician workforce deficits. We clearly need to create networks of care that link various providers with optimal efficiency and oversight. To achieve this goal, we may be able to learn from the African experience with surgical assistants.

The intersection of public health, population health, and health care delivery requires physicians who can see beyond the pathological processes of individual patients to understand the broader context of disease in a community. Current payment systems may not provide adequate incentives for such thinking, but it is critical to consider the prevention of disease and the management of chronic disease when faced with limited health care resources. The MEPI deans struggled with how to maintain their connection and commitment to primary care and prevention in their communities while building a faculty with advanced skills and knowledge in the care of patients with complex diseases.

MEPI supplements

Finally the importance of research, program evaluation, tracking of graduates, and the dissemination of results through publication was reiterated and endorsed. These actions require the collection and analysis of data and the skills to communicate the results to others. We must continually reexamine and reevaluate our investment in innovative projects like MEPI and open them to public scrutiny. The MEPI supplement helps to fulfill this goal and provides a snapshot of the individual programs currently underway. I congratulate all who contributed to this effort and believe it will be seen as a landmark in the evolution of global health partnerships.

  1. Mocumbi AO, Carrilho C, Aronoff-Spencer E et al. Innovative Strategies for Transforming Internal Medicine Residency Training in Resource-Limited Settings: The Mozambique Experience. Acad Med.2104;89:S78-S82
  2. Child MJ, Kiarie JN, Allen SM et al. Expanding Clinical Medical Training Opportunities at the University of Nairobl: Adapting a Regional Medical Education Model from the WWAMI Program at the University of Washington. Acad Med. 2014;89:S35-S39

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