A great resource for teaching doctors in Africa how to find, organize and use information….

I came across an interesting group African Medical Librarians and Deans - who have put together a number of online courses and presentations addressing internet literacy among medical students. This is an example of how the approach to ehealth in Africa will most certainly be different in Africa compared the America. Most people in the US are computer and/or web-literate. Certainly medical students have the skills to use both. But in Africa where students come from different backgrounds, including rural areas, computer literacy is variable. Starting from the basics is essential not only for students but for faculty alike. This particular website has seven modules addressing finding, organizing and using health information. Interestingly, there’s a module here called Scholarly communication in which the latter part discusses how to write a journal article. Ironically, this type of information/training would even be helpful for American medical students!

mHealth in Africa – examples of success.

Just read a great article on mobile phone use in Africa. It’s a topic that’s become quite popular but reading about specific examples of success and one that even reports the number of hours and money saved. This article gives the following examples of mobile phone use

• Pill bottles that tell doctors when a patient has taken meds
• An application that allows patients to send a text to their doctor even when they have no money left on their card to say “call me”.
• Tracking disease information
• Reminders on the phone for patients to take their medications
• Phones for doctors serving in remote areas with clinical decision support tools.

I think the use of mobile phones is going to change the playing field in healthcare in Africa. The last example in the article talks about Medic Mobile and how a pilot project in Malawi saved 1200 provider hours and $3000 in transportation costs. This is great data.  The more data like this we gather, the more likely mhealth will be funded and embraced in large-scale.

When I was in Uganda last month and one interesting thing I noticed was the use of mobile phone GSM technology providing wireless internet in the rural areas. We went to Kayunga Hospital which was about a 2 hour drive outside of Kampala and the clinic computer room there was using this technology (along with solar panels for electricity). Many people told us of this technology being used for wireless internet (it’s a bit slow, can be inconsistent but it works)

I’m hoping to attend the NIH mHealth Summit in December to learn and hear more about this exciting field.

How the mobile phone will soon help Kenyans find a Doctor

This is very cool – set to launch on October 1 this could really change the playing field of mhealth – next on deck is using mobile phones to enable training in the rural sites.

“medAfrica from Kenyan startup Shimba is a phone-based medical reference and real-time public health tool meant to dramatically increase the well being of Kenyans, and eventually people throughout the developing world. Similar in many ways to Indian company mDhil, the smart phone version of the app allows a sick individual to check his or her symptoms against an encyclopedia of ailments, such as fever, swelling or other maladies, and the tool will allow them to call a relevant medical professional with a single click.

There are 40 million people in Kenya, and only 7,000 doctors nationwide. There’s too much knowledge locked up in too few heads, as co-founder Mbugua Njihia quipped from the stage during his presentation. Their app helps to narrow this knowledge gap in many important ways. And while smart phone penetration is steadily rising throughout Kenya and Africa as a whole, the real power comes from medAfrica’s ability to deliver health information to remote areas through the use of SMS.

What works in Africa can work anywhere, in terms of scale and internationalization, and the team believes that if they can reach 200 million downloads, at $10 of revenue per customer per year, they will be a billion-dollar company within five years.”

How do you incentivize resource-strapped medical schools to embrace open access?

It sounds obvious that medical schools in developing countries should share curricula. That open access is the way to go to address the severe shortage of doctors, and especially of faculty to train doctors. In fact I think there’s a real opportunity out there for someone to create a destination site that would have  comprehensive collection of lectures, articles, curricula for a complete medical education.  I’ve seen a number of potential sites recently – Science Supercourse and even OER has a few courses posted under ‘medicine’, but there doesn’t seem to be a definitive leader in this space.

And as I understand it, to create open access material you need to have your material licensed so that it can be shared, reused etc…I haven’t done it myself but expect that it does take some time to deliberately prepare your material to share. Enough time and effort that this is one of the primary services offered by OER.

So the challenge, in my opinion, is how do you incentivize resource-strapped medical schools in Africa to go through this process and make their material open access? I don’t doubt their intentions,  but why should they spend the time it takes to obtain the licenses and make their material ready for open access when they have more pressing challenges on their minds? There may be exceptions such as Stellenbosch University, who already have elearning material ready to share and do so, but most schools are still trying to develop content for their elearning programs.

This might be an opportunity for a grant, a competition or for partner schools in developed countries to take on as their social mission. Given the shortage of doctors, the shortage of faculty and the fast pace of new medical schools in Africa, increasing open access material and establishing a definitive destination could make a huge contribution to the field.

The question is – how do you get this done?

 

Medical education programs in Africa should follow the trend and start doing homework in the classroom.

The Khan Academy is changing the way the world approaches education. Sal Khan (an MIT grad) provides 10-minute online tutorials on thousands of topics. He makes complicated topics easy to understand. He’s a gifted teacher, he doesn’t charge tuition and you can listen to him at your own pace. You can stop, rewind, fast-forward or replay.  This is revolutionary. While the traditional model is you go to school to hear the lecture and then go home to apply the knowledge, Bill Gates and Sal Khan, through the Khan Academy are suggesting that we should switch those activities around.  We should get the best teachers in the world to provide lectures online, then students can listen at their own pace. Students come to the classroom to do problems, apply their knowledge and get tutored/mentored by the teacher when they get stuck.  It’s already being tested in schools across America.

Now think about this in the context of medical education in Africa. Throughout Africa the biggest challenge is the lack of faculty…not enough teachers. In Ethiopia the government plans to train 20 thousand doctors by 2020 so medical schools are challenged by trying to teach upwards of 300 students in a class. In Zambia though the classes are not so big, there just aren’t enough basic science faculty to teach in the pre-clinical years.  So what if we apply this model. Take the best teachers in the school, city or region and tape the lectures. Give students access to these lectures by video, CD, intranet or internet. If the resources are really limited, you can just give them the reading material but expect them to come to class prepared.

Then when students gather in the class, they spend their time doing what used to be their homework, i.e. solving problems. Working through a case. Teaching each other and trouble-shooting together. The strong students will help the weak students. Together they will make their knowledge come alive. They don’t need experts in the room to teach, they just need facilitators to answer questions – these could be post-graduate students, senior students, junior faculty etc.

This model is already being used in some schools referred to as Team-Based Learning (TBL). At my institution, George Washington University, we use TBL in Anatomy. There are already schools in Africa such as the Kilimanjaro Christian Medical School using it in medical education.

As countries throughout Africa try to train more doctors with few faculty, they need to consider new models of delivery. It’s learner-centered, team-based and efficient on faculty time and expertise.  The Khan Academy is really on to something….

Can community-based training convince medical graduates in Africa to stay?

How effective is community-based education in retaining graduates in rural service?  The literature on retention focuses mainly on approaches that are in the hands of the government – increased financial incentives, housing, good work environment, opportunities for professional growth and development and more. So what can medical schools do to address the issue of retention? Most of the literature supports rural recruitment programs – suggesting that students recruited from rural or remote areas are more likely to return to work there.

That said, Ethiopia is one example where recruiting is centralized. High school students take a national exam, those with the highest grades can attend medical school but there is no specific rural recruitment quota. The government does have a compulsory service program where graduates are required to do public service after graduate. For those who choose to go rural, they can complete their rural service in a shorter time.

So what can the medical schools do to encourage rural service? According to a WHO technical document on rural retention strategies training in the community can work. But how much community training and what kind of community training is effective? Does one short rotation work or do students need a longer experience of several months duration to really appreciate the impact they can have? Many medical students do one community-health rotation where they do both clinical and public health research.  Other medical schools like Jimma University in Ethiopia, have threaded community training throughout their curriculum, facilitated by their location closer to community/rural clinic.

So for medical schools based in urban settings, is a short community rotation enough to convince students to work there or are the scant accommodations, the social isolation and the lack of IT connectivity a deterrent?

As I survey medical programs across Africa, the majority of schools have some form of community training yet the literature has very little about the impact of this training on rural retention. Given the continent-wide crisis accessing a physician in rural areas, training programs should do a better job of evaluating the impact of these experiences and publishing the positive and negative results. Is it frequent short-bursts of exposure or one long-term exposure that has a better chance of retaining medical graduates? Time to figure this out….

Should the US pay Ethiopia for each doctor that chooses to move to the States?

I heard a great BBC podcast on the brain drain in Ethiopia and it got me thinking about creative solutions to old problems.  I’m in Ethiopia right now and fascinated by the country’s approach to flood the market with doctors to retain the numbers they need.

The brain drain of physicians trained in Africa to the US, Canada and other developed nations is an on-going challenge. In Ethiopia, a country of over 80 million people, there are only 3000 physicians. To address this challenge, the country plans to scale up in large scale the number of medical schools and therefore physicians trained in the country. In essence, they plan to flood and retain. At public medical schools (which are the majority), medical education is free, then graduates are expected to complete compulsory service of 2-4 years in country. After that, physicians are free to go wherever they want. Many go to western countries to complete residency training, others go to NGOs in-country and others go in to private practice – all options that pay more than public service where then need is most acute.

So if Ethiopia is investing in to provide medical education to thousands of students each year, only to supply richer countries where access is not nearly in as much a crisis, shouldn’t we pay for their service?

Medical education for a US student costs around 250K – now granted a good portion is paid by students but States often subsidize higher education, so shouldn’t we pay back some of Ethiopia’s investment, especially given the huge deficit it leaves behind?

The issue of retaining doctors should clearly be addressed by the Ethiopian Ministries of Health, Education and the medical schools but perhaps it’s time the West takes some responsibility for the brain drain?