September 2, 2008

A Global Approach to Training

By Yvonne Cook

The Open University is supporting a new medical school in Ethiopia that's also providing a base for distance learning. Yvonne Cook reports

Ethiopia has a population of 84 million people, and fewer than 1,800 qualified doctors. Many people, particularly the poor, cannot get access to a doctor when they need one. The Ethiopian government is making strenuous efforts to improve the situation; it has plans to create 11 new medical schools with 8,000 new places over the next two years. But the shortage of doctors means an even greater shortage of qualified people to train them. Worse, 95 per cent of all the doctors the country trains leave to work overseas within two years of qualifying.

It's a scenario that's familiar in many African countries. But in Ethiopia's case, there is a ray of hope. The Ethiopian government has given its support to a new medical school with a radical approach to recruitment and training which could turn around this bleak situation.

St Paul's Millennium Medical School in Addis Ababa opened its doors to its first 50 students in March this year - in the Ethiopian calendar, our 2008 is their Millennium year. And following discussions with the Open University, the Ethiopian government has approved a plan to use the school as a base for a distance learning medical centre to develop a curriculum which can be used to support medical students' training anywhere in Ethiopia, and even elsewhere in Africa.

Mike Stewart is professor in neuroscience in the Open University's Life Sciences department. He is working on the first phase of the project, and is planning to prepare OU-style training material for the medical students at St Paul's.

"The medical degree programme will be a combination of different types of learning - a term that's used a lot now is 'blended learning'. In the first years when students are on campus they will get face-to-face lectures and clinical experience as well as using internet resources and specially prepared distance-learning style workbooks. Eventually, when they go out to work and train in the regions, they can have the teaching material we prepare sent out to them there."

A key advantage of the OU approach is that it can be scaled up, quickly and cost-effectively, he says. "If you have a course for 50 students, you can have a course for 500 students, basically you just produce more of the material. And it doesn't just have to be studied at St Paul's, it can be the basis of the other new medical schools in Ethiopia, or even support medical training elsewhere in Africa."

The project is being masterminded by the Open University's Centre for Education in Medicine (OUCEM) which has already created successful distance teaching programmes for HIV/AIDS treatment in India and diabetes care in Bangladesh. But a full medical degree using distance learning will be a world first, says OUCEM's head Professor Janet Grant.

"It has never been done anywhere before, but all the design work has already been completed. Several years ago Professor Stewart and I led a project looking at the feasibility of teaching medical students in the UK by distance learning. We worked with 11 other UK medical schools to design medical education using distance learning and the work was approved by the Higher Education Funding Council for England, the Department of Health and the General Medical Council.

"It's not a case of 'Oh dear, this is all we can do in Africa'. St Paul's distance learning medical centre is going to be a world- class medical school. It is not what people usually think of as distance education, which is students studying on their own. It involves all the richness of a normal curriculum - the face-to-face and clinical element is part of the whole."

The St Paul's distance learning centre adds another dimension to what is already an innovative project. This is largely thanks to its founding dean, Professor Gordon Williams, a distinguished urological surgeon at London's Hammersmith Hospital who retired last year to devote his time to St Paul's.

Williams had been visiting Ethiopia for the past 23 years during his holidays, to perform surgery on women and girls being treated for childbirth injuries at the Fistula Hospital in the Ethiopian capital Addis Ababa. The consequence of a lack of medical attendance in childbirth, aggravated by a tradition of early marriage which means girls give birth before their bodies are sufficiently mature, fistula is a horrific condition which leaves victims with ruptured bladders or bowels. As well as suffering debilitating incontinence, they are often ostracised by husbands and families.

As a result of his experiences at the Fistula Hospital, Williams became convinced of the need to train more people to perform the emergency surgery which would prevent these childbirth injuries from occurring in the first place. Following discussions with the Ethiopian Ministry of Health in January 2007, he was invited to become dean of their new medical school based at St Paul's Hospital in Addis Ababa. Williams returned to England and raised just over a quarter of a million pounds for books, computers and medical equipment to get the school up and running.

When he took on the job he was shown a curriculum which was the one used by other medical schools in Ethiopia and very similar to the one he had trained on himself. "Having had 40 years of experience of working as a doctor, there's quite clearly large chunks of this curriculum which are completely unnecessary to me, and even more unnecessary to people who are going to be working in rural Ethiopia," he says. "So I really cut it down, so that we could train interns in three and a half years."

After completing their initial training on campus the St Paul's students will go out to work for the state in district hospitals, under supervision, while they continue to learn and be assessed. The end result will be doctors who are competent in skills such as emergency obstetrics, gynaecology and surgery after five and a half years training, says Williams. "The great thing is they will not go out to work in the rural areas lacking confidence and competence; they will have been assessed and will be capable of working in isolation, dealing with patients who are acutely sick - life-saving stuff."

Williams is no stranger to curricular innovation; as chair of the UK's Joint Committee on Higher Surgical Training he spearheaded the introduction of an innovative web-based surgical curriculum. As well as increasing the speed and relevance of training in Ethiopia, Williams also hopes to increase the number of doctors who stay in the country after qualifying, by placing greater emphasis on applicants' motivation and background during the selection process. Fifteen out of the first 50 students have been taken from the four poorest districts in Ethiopia, and just over half the students are women. The students are so enthusiastic that Williams has to enforce breaks from study by closing the library. They combine basic science and clinical and community practice from day one, says Williams. "They see their first patients in the community on their fourth day of medical school. It is really exciting for them, they have their white coat on and we give them a stethoscope and a machine to take the blood pressure and they're off. And they work in the wards in the evenings, with the nurses, so they learn how to make beds, how to wash a patient, how to give them a bottle or a bedpan."

Currently Williams is relying for teaching on a stream of volunteer doctors from the UK, who fly out for anything from two weeks upward to give lectures. Many are senior medical students in their elective period - a three-month work experience period allowed to those who have just passed their final exams. "I couldn't do without them," he says. "We have had a succession of fantastic students who have really enjoyed themselves, teaching but also learning what the diseases are here and how they are managed in a country which is incredibly poor." This system, though, can never train the large numbers of medical students the Ethiopian government wants. "The only way that those doctors can be trained is by using distance learning. The government are setting up new medical schools in towns with a hospital, so the hospital will provide the students' clinical needs, but the lectures and the other things that they need for their guidance can be taught using distance learning."

The medical teaching package planned by the OU will have many aspects familiar to its UK students - textbooks, DVDs, experiment kits, assignments and study support - plus other innovations to suit the circumstances, as Mike Stewart explains. "We are looking at things such as videoing the lectures that visiting experts give, and making them available on an intranet system so students can log on and get lectures online." The OU has also been involved in talks about collaborating with other organisations involved in health training in Ethiopia in areas such as IT infrastructure, which needs to be improved before the potential of online teaching can be realised.

"It is very exciting," says Grant. "The project has taken on a whole Pan-African dimension. We have been talking with colleagues in South Africa, Tanzania and elsewhere who want to do the same thing and will help us develop the material. Only last week we have had interest from the Brazilian government who are looking at something similar for Mozambique and Angola. In Africa, given the shortage of people to train medical students and the way people are based out in far-flung regions, it is the only solution. The only thing we need is the funding to ensure we can continue with the OU's involvement in the programme."

For more information visit training_doc_project.shtm Volunteer doctors interested in working at St Paul's should contact [email protected]

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