My recent work in Azerbaijan convinced me that reforming medical and public health education programs is critical to revamping clinical processes and public health practices for effective prevention, diagnosis and treatment of diseases and injuries. In this small Caspian Sea country, improving physicians, nurses and public health specialists’ educational programs—which are hampered by outdated conceptual and methodological structures and practices—is starting to receive priority attention in the country’s quest to improve health system performance.
The challenge is shared globally, as different countries are struggling to sufficiently staff their health systems with well-trained, deployed, managed and motivated physicians and nurses to provide quality medical care, and competent staff to manage service delivery and carry out essential public health work such as disease surveillance.
With few exceptions, such as the 2010 Lancet commission report*, medical, nursing and public health education reform has failed to appear in the international health agenda—yet we continue to focus on employment and remuneration of existing personnel. This has to change. Why? Simply because the adoption of and adaptation to local conditions of new knowledge, country experiences and good practices help accelerate social and economic development.
The extraordinary progress in medical knowledge during the last 50 years, coupled with the introduction of new technologies, drugs and procedures, and the promise of more profound and rapid changes in the future catapulted by the “genome revolution” and evidence from different disciplines, clearly point out that medical and public health education programs cannot remain static. They need to continuously change with these developments and serve as the “conduit” for channeling new knowledge to reform medical and public health institutions and practices.
Education reform requires well planned and systematic efforts. In Azerbaijan, the Ministry of Health and the State Medical University, with the support of the Royal Society of Medicine and Barts and London Medical School, initiated the revision of the fragmented medical education curriculum by defining aims, outcomes and structure of the whole program, for each year, and for core modules. The country is also adapting new learning and training materials in the local language; introducing laboratory training (e.g., bedside teaching, using equipment) to develop the clinical skills of students; replacing oral examinations with test-based assessments to objectively measure student performance; supporting training to improve the knowledge and teaching skills of professors; and introducing a national licensing examination for recent graduates to determine who is fit to practice medicine.
Similar efforts are underway for post-graduate medical training through the introduction of residency programs for specialists. In January 2011, a mandatory accreditation process began with the standardized, computer-based testing of practicing physicians for the issuance of medical licenses. The effort to reform medical education will need to be accompanied in the future by similar reforms in nursing and public health education.
It is too early to measure the impact of the education reforms in Azerbaijan, but other countries may do well by emulating this experience. And international organizations and donors need to support this effort not only to help ensure that future physicians and nurses, as well as public health specialists, are well prepared to tend the health needs of the population, but to sustain ongoing health care organization and financing reforms.
* “Health professionals for a new century: transforming education to strengthen health systems in an interdependent world.” The Lancet, Volume 376, Issue 9756, Pages 1923 - 1958, 4 December 2010.
Indeed Martin. New medical and public health education paradigms and curricula rooted on evidence are needed along with the careful crafting of strategies adapted to local realities to ensure buy-in, acceptability and engagement on the part of policy makers, faculty and service providers. The good news is that there is a tangible yearning for new knowledge and skills among current medical staff, public health practitioners, and students that offers a good entry point for the international community to support well-planned, systematic changes over time. But as you say we have to be realistic and not to expect that change will occur overnight.
The need for reform of medical education in the former Soviet Union is compelling. Even now, many medical schools are teaching material that is devoid of evidence - see: http://bit.ly/vAGlSo
The excellent work that Patricio and his colleagues have been doing offers a model for neighbouring countries. The task is great and we need to be realistic about how long it will take to yield results in terms of improved quality of care. However, this is a very good start.
Your point is well taken. To a large extent the Flexner Report of the early XX Century continues to dominate medical education. And as witnessed in different developed countries, such as in the United States, more and more there are calls for sweeping reforms in medical education to make it more relevant for helping reduce social disparities, facilitate opportune access to quality of care in redesigned health systems, and improve health conditions by focusing not only on the biological determinants of disease but also on the social and environmental causes. So, as you clearly indicate, this is a challenge for developing and developed countries alike.
"... reform has failed to appear in the international health agenda—yet we continue to focus on employment and remuneration of existing personnel"
This same situation is occurring in the field of education as well. The "old guard" trying to hold on to what they've got. But, it's not just the under-developed countries that need reforms. Some of our higher industrialized nations are in desperate need of it also.
The political dimension of medical education reform cannot be underestimated as you indicate. It is indeed imperative to ensure the active participation of the different stakeholders, particularly of professors, in defining and implementing the process of change. The latter observation is of utmost importance for example to ensure that curriculum change is accepted and sustained. And twining arrangements with other teaching centers and with specialists "who have done it" help pave the way--a peer to peer partnership.
Dear Patricio, thank you for calling attention to this very important subject and for highlighting the progress being achieved in Azerbaijan. As you pointed out, health education reform is a big challenge in almost every country, and there is broad consensus that if health care delivery is to be improved, better education of the healthcare workforce needs to be attained.
Yet perhaps one of the main difficulties in developing countries is implementing sustainable education reforms that optimally prepare healthcare professionals to address the evolving needs of the population, especially amidst the rapidly declining availability of resources for both health and education. Another key challenge is the heavy resistance to change that is characteristic of the health care and health education institutions, not just in the public sector.
Certainly, new technologies (e-CME, e-learning, telemedicine, telemonitoring, e-surveillance, etc.) offer huge opportunities to reduce costs while improving quality and coverage of higher education and healthcare. However, besides the lack of adequate resources, perhaps the most difficult challenge facing health education reform in developing countries is the lack of political commitment and effective leadership to carry out the required reforms.