PREAMBLE

Traditionally medical schools in Anglophonic developing countries have been planned on the design evolved in Britain. However, with the different contextual influences, such designs appear inappropriate when transposed directly into the developing world.

Problems which have been known to arise in existing medical schools in developing countries include:

1.      Recruitment of students.

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   1. Applicants seem frequently to not have a full and enlightened understanding of the requirements of being a doctor.
   2. Motivation to apply for training might be driven by spurious factors, such as inappropriate aspirations towards status and wealth.
   3. A percentage of applicants appear to intend their training to be a vehicle for emigration.

1. Selection of students.
   1. Reliance on school examinations. These, often founded in the distinct cultures of the 1^st World are, at best, a crude method of determining the commitment, fortitude, decision-making capabilities and practical skills required of the aspirant doctor. Some medical schools rely solely on “A level” marks as the admission criterion.
   2. Nepotism and political factors, which influence the selection of medical students often, pervert the formal structures of selection. 

1. Standards and examination mechanisms.
   1. Recruitment of appropriately skilled Faculty is difficult for reasons which include:

                                                               i.      Finance.

                                                             ii.      Reluctance of first-world recruits to live in developing countries.

                                                            iii.      Absence of research facilities.

                                                           iv.      “Indigenisation”, where political veto is placed on non-nationals, etc.

                                                             v.      Strategies by governments, using the health services and the medical schools as instruments of political display, which might conflict with the beliefs of imported staff.

                                                           vi.      The reluctance of some governments in the developing world to give long-term or permanent residential status to imported staff. The resultant insecurity of tenure militates against these individuals giving whole-hearted long-term commitment to their endeavour.

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   1. Perverse pressure. Faculty are often victims of extraordinary pressures to pass and qualify sub-standard students. These pressures might be particular, as in nepotism and bribery, or more general, as in political pressure.

One of the precepts held in this design is that the faculty should be relieved of those risks and an independent authority should conduct the progressive, in-training examinations, at least until the appropriate standards are well established.

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   1. For similar reasons, external authorities should probably manage the qualifying (exit) examinations initially, to accepted international standards.

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   1. International accreditation. There are benefits to medical schools if accredited internationally, such as:

                                                               i.      Allowing its pre- and postgraduates a maximum exposure internationally. 

                                                             ii.      Facilitating exchange programmes.

                                                            iii.      Credibility in applications for funding.

                                                           iv.      Participation in international research and similar. 

Intended non-recognition. There is a philosophy in a number of developing countries that it should not be made easy for graduates to leave that country and the hurdle of “non recognition” is often placed in their way. This is effected by planning to not meet some or all of the standards required for international recognition.

This is, of course, a political philosophy and no value judgment is implied.

1. Finance. Exceptional financial strains face medical schools in the developing world. 
   1. The costs of teaching and examining are the most significant factor, particularly when tenured or “in house” Faculty is employed.
   2. Appropriately selected medical students might be impoverished. Mechanism must therefore be established to loan funds, possibly to be repaid by service to the funder: the State or Region, missionary organisations, charities, industry or the military could be considered as potential funders.
   3. Libraries. The stocking and maintenance of libraries in the traditional fashion is financially unworkable in the developing world currently. Instead the computer-accessible databases must substitute entirely for the traditional library.

1. The quality of existing hospitals to be used as teaching hospitals.
   1. Not only might these be inferior for teaching on a number of levels, but a grave danger exists that students in these hospitals could readily learn to regard inferior practice as an acceptable norm.
   2. It is equally important that the students learn cost-effective and economical patterns of practice as appropriate to their countries. This can often only occur in the hospitals of developing countries.

The following design is suggested as a means of addressing some of these limitations.

PRE-ENTRY YEAR ONE

A year of nursing training in a 1^st World institution [[i]]. In parallel with that, theoretical anatomy and autopsy room anatomy. 

Pre-entry exposure is suggested for the following reasons:

1.      This brings forward the internship to entry level, rather than the exit levels of training. Although the concept of an internship, as a consolidation of theoretical knowledge is understandable, the reality is that the intern, particularly in the developed world, has a role of minimal and diminishing responsibility as litigatory concerns increase. The intern, in reality, does very little more than have an “observation role”. There seems every reason to believe that this “observation role” could be undertaken as the first stage of training: consider the practical information acquired by a first-year nurse, and extrapolate that to individuals who, anticipating selection into a medical school, will have high information-acquisition capabilities and who should be able to capture within this year an extraordinary range of knowledge of the day-to-day application of medicine.

2.      Reintroduces the “apprenticeship” aspect of medical training with these benefits:

                                                               i.      It will allow aspirant doctors to understand the profession to which they aspire. Just as it is indulgent for persons in the developed world to enter an expensive and protracted training (often at great cost to the government) without first fully understanding what their end role will be, that expense and time lag are far less affordable in developing countries.   

                                                             ii.      This will allow the profession an insight into the potential of applicants from within the medical profession. It is anticipated that an exacting appraisal will be made by the employing institution which will contribute to subsequent assessment for selection to the university portion of the curriculum. This is not without precedent, an example being the “Pre-Med” training in North America. However, selection by such preliminary intense academic training is not appropriate, nor practical, in developing countries, and this is seen as an alternate approach. 

Horizons of excellence. It is envisaged that this first year of “apprenticeship” be undertaken at an institution of high calibre, ideally in the developed world. The reason is that many training hospitals in the developing world are of sub-optimal calibre and there is a great danger at this stage that the highly impressionable student could be contaminated by the inefficiencies, lethargies, insufficiencies, and other undesirable forms of practice. The aim would be to display to medical students, as early as possible in their careers, standards of excellence to which they would be expected to aspire.

“Bottom up” training. Modern medicine exists in complex environments in which the aspirant doctor needs to learn a high level of practical, interpersonal, and perspective skills. Much of modern medicine is practised in institutions that have as their foundation, both in history and in practice, the “hotel”. Whatever role the doctor might play in his ultimate career, it is important that he should have a full understanding of the functions of the “hotel” component, as well as the nursing and the many other contributors to the logistics and maintenance of the day-to-day running of hospitals. It is hoped that the necessary insight, recognition and respect for the medical support services could be inculcated at this stage. The conventional postgraduate intern, having been granted the title of “doctor”, is ipso facto distanced from the contributory experience of other health carers. It has been consistently observed by the author that many early graduates have delusions of superiority and capitalise upon their title to intimidate or evade what could be authoritative instruction from other healthcare disciplines. The anticipated advantage of the “pre-internship” is that that individual would be expected to be a “worker”, and to follow the instructions of senior persons, whether they are in the nursing, medical or other fields, and learn the daily mechanics of hospitals. This, of course, is no different from the hotel industry, where aspirant managers will begin “at the bottom”, and gain foundational knowledge of the workings of the institution, before maturing to a position of authority and management responsibility.

Academic component

It is anticipated that in this year a theoretical knowledge of anatomy will be acquired, to a pre-set curriculum and measured by multiple-choice questionnaires. This will be supplemented by autopsy anatomy, i.e. a combination of pathological and gross anatomy, acquired by attendance at the routine autopsies of the hospital. These would, presumably, include the occasional autopsy on persons who had been nursed by the student, giving a superior vision across from the theoretical to the practical.

Theory enhancement. It is believed that this practical foundation in the “real world’ will enhance, in the most forceful way, the subsequent academic learning. Interpretive skills would then be developed on a strong foundation of the practical implications revealed by subsequent formal academic instruction.

Finance. It is hoped that this first pre-internship year, conducted in a first-world country, would allow the “pre-intern” an income. It is anticipated that this would be sufficient to meet the costs of travel to the centre of excellence, and perhaps allow a small residue for use after return to the developing country. It would also be hoped that arrangements could make this a tax beneficial, by both the hosting country and the country of origin, to enhance this accrual.

Enlarged selection pool. Admissions to the Pre-Entry Year would be larger than the available positions in the medical school. The inclusion of persons who would have been considered inappropriate for entrance to medical school using current, conventional selection techniques will allow a broader pool for eventual selection, and satisfy those who would feel wrongfully excluded from entry to medical school by too narrow or too limited criteria.

It would be expected, at the end of the second Pre-Entry Year, that there would be attrition of aspirants for Medical School entry. Further, a number of individuals might now choose to continue nursing, or branch into other disciplines within healthcare. This is to be encouraged, since the philosophic foundation of “apprenticeship exposure” will be as important in physiotherapy, laboratory technology, radiography and others. The choice of discipline by the student, at this stage, is expected to be enhanced by their exposure to these disciplines in the workplace. 

Such a supply of these apprentices to the ward-work during the Pre-Entry years would bolster the workforce into, and likely recruit interest in, healthcare as a profession.

Those who choose to continue with nursing would naturally be given credit for this training.  

PRE-ENTRY YEAR TWO

Second-year nursing training plus theoretical physiology.

Rural internship. It is proposed that this year will be in the country of origin of the potential medical student, ideally in rural and peripheral institutions for the following reasons: 

1.      Training in urban centres (as it usually is) gives little insight into the requirements of the periphery of a county.

2.      Their presence will add to the staffing levels, in areas which are notoriously depleted by migration to urban centres. 

3.      This will have a strong politically satisfying value, in that the individuals will be returning to “the people”, and so reassure those in the periphery of the country that there is at central government level a concern for their plight and that the doctors of the future will have an understanding of their circumstances.

Enhanced interpretation. Like Pre-Entry Year One, this year will also offer the foundation for a fuller interpretation of the ultimate academic training, but with an understanding of the distinct pathology and management challenges of the peripheral areas of developing countries. 

Selection appraisal. This year will repeat the exposure of the individual to the profession and the profession to the individual, but by an entirely different and independent group of individuals. In this instance selection will be by the people who will ultimately be the recipients of those professional skills. 

It goes without saying that any students who are not prepared to work in these rural environments for a year disqualify themselves from admission to medical school.  The converse of this is that it is likely to give the students sufficient insight into rural work to make it voluntarily attractive. 

MEDICAL SCHOOL YEAR ONE

FIRST HALF-YEAR: COMPUTING SCIENCE AND LOGIC

Computing Science. It is not possible to conceive of a doctor of the future who is not fully and totally conversant with information and communications technology.

It is contemplated that the students of this course will depend primarily on computer learning.

High levels of computing skills will be necessary for the obligatory ongoing learning of the next generation of doctors.

As a source of reference the Internet will be the only effective means of keeping abreast of worldwide developments in medicine. This will be particularly applicable to developing countries.

High levels of recording and retrieving patient information economically will only be possible if computers are utilised. 

Research possibilities will be broadened using the computer, and low-budget research will become more feasible.

High-budget research and sophisticated statistical measurement will only be possible using computers.

Formal logic. Apart from its derivation from a deductive science, the practice of medicine is involved primarily with pattern recognition and deductive conclusions. Further, the majority of medical errors can be attributed to incorrect assumptions. These skills in logic are what differentiate the good doctor from others.

Surprisingly little or no formal instruction in these skills has been built into medical curricula. Instead the assumption is that such skills are “intuitive” or “develop spontaneously”. This assumption is incorrect. A background in formal logic is rated by some prestigious universities as the prime learning discipline upon which further academic accomplishments will be based.

SECOND HALF-YEAR: PATHOLOGY AND BIOCHEMISTRY

This semester will introduce the following proposed teaching format: 

The use of lecturing as a means of transmitting knowledge can be considered unsatisfactory for the following reasons:

1. The quality and availability of lectures in the developing world is initially likely to be less than optimal.
2. The employment of lecturers is an expensive component of a higher institution, particularly since a large amount of this knowledge is available elsewhere.
3. The retention of information from lecturing has been found by many studies to be poor, and ineffective.

It is suggested that the traditional formal courses of lectures be replaced by the following three divisions into five-week “blocks”:

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   1. Self-instruction. This will be based on a detailed syllabus developed by the university. Ideally this syllabus will emphasise hierarchical importance.

The students will then acquire the information by any means they choose, but primarily this will be via the Internet through a variety of search engines.

Multiple-choice examination to be set and computer marked by an independent authority at the end of the self-tutoring period. It is anticipated that this will be more objective and cost effective than traditional examinations set and marked by resident Faculty.

If appropriately designed, such testing will allow constructive feedback to the university, allowing the syllabus to be developed in an evolutionary fashion.

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   1. Focused tutorials. Using the examination results as the guide, the following five-week block will comprise tutoring on focused areas of learning weakness to provide individual or group revision and assistance.

Peer Tuition. It is proposed that those students who have examination-proven knowledge in some areas be matched against those who have poor knowledge in the same areas to provide peer instruction. Not only will this be cost effective, but also it is likely that high levels of efficiency of teaching will result. A further and important benefit is that it will give the student-teacher experience in communicating, allow a consolidation of their own learning, and enhance teaching skills in those students – the potential next generation of Faculty.[[ii]]

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   1. Clinical attachment.

In this year the clinical attachments will be to various branches of the pathology and perhaps radiology services. This is to emphasise the need for these graduates to have that polymath capacity which is so frequently required in underdeveloped countries. For example, the individual might need, in the rural context, to cross-match blood, perform radiology or execute an autopsy: all without assistance, except possibly by telecommunication.

Staggering of teaching. A benefit of this structuring is that the five-week periods can be staggered, (although the five-week self-tutoring period must always be followed by the five-week focused tutorial period). Therefore, and if needs be, effectively three “streams” of students, one third of the class, would be engaged in any one five-week block at a time. This will allow smaller numbers in each five-week block, and therefore a higher staff to student ratio and lower numbers in the clinical attachments

SECOND AND SUBSEQUENT MEDICAL SCHOOL YEARS

Cyclical self-teaching and tutored instruction, interposed with clinical attachments to encompass the range of specialities, including general practice, as previously described, is proposed.

It is not the purpose of this broad-brush and conceptual paper to provide a detailed syllabus of each of the specialties and sub-specialities. In general terms these will conform with those of the developed world, biasing emphasis to pathologies more prevalent or unique to particular countries.

[i] Currently many first-world countries have a policy of charity towards the third world. The current inclination is to fund less but instead provide services of direct benefit, particularly to the poorest. It is believed that sponsoring or subsidising the employment in the donor country of nurses fulfilling the pre-internship requirement would meet those specifications of donor nations.

[ii] This has worked well in established universities.. Student/peer instructors were usually (but not always) one year ahead of their pupils and were paid by the department concerned. Well documented at other tertiary institutions. I believe this is our most underutilized resource for instruction and is supremely effective.