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Enhancing medical education in Africa: global perspectives on medical practice.

A desire for travel and exploration and a dedication to students have been two driving forces in Dr. Michael Alkan's career as an internist and an educator.

"I went into the area of infectious dis ease because--with the current exception of AIDS--people can get well," Dr. Alkan said. "But there was a hidden agenda. I love to explore and travel and this specialty lends itself to that."

Dr. Alkan's career of practicing medicine overseas began in 1980 when he led a team of Israeli doctors and medics to work in a field hospital in a refugee camp on the Thai-Cambodian border.

"We ran the emergency room (shack), and it was a formative experience," he said.

Dr. Alkan studied medicine in Jerusalem and trained as an internist at Hadassa Hebrew University, from which he graduated in 1966. He followed this training with fellowships at the University of Tennessee, Memphis, and he has taken sabbaticals at the University of California, Los Angeles; Wayne State University, Detroit; and Beth Israel Hospital, New York.

In 1989, Dr. Alkan traveled to Africa to work in Kenya under the sponsorship of the Ministry for Foreign Affairs in Jerusalem, and he was hooked on global medicine. "The rest is history," he said.

That history includes pioneering research in infectious diseases in Africa and Southeast Asia, treating patients in Botswana, and educating local health care providers about infectious diseases including cholera and enteric disease. Dr. Alkan has contributed to more than 100 articles on infectious disease and continues to teach infectious disease courses, including a recent course on AIDS in Nairobi.

Most recently, he has been involved in teaching at newly opened medical schools in underserved areas, which often face rapid growth with a limited faculty.

Dr. Alkan is retired from Soroka Medical Center, but he teaches at the School for International Health at Ben Gurion University and at the school for social work at Sapir College in the Negev, all in Israel. He shows no signs of standing still for too long.

"I'm traveling to Sichuan, China, in November to help with reconstruction after the earthquake and the flooding there," he said. "In February 2009 I plan to be in Cambodia, working with Israeli volunteers, and in March 2009 I will be advising the Patan Hospital, Kathmandu, Nepal, on the opening of a new medical school."

What has been the nature of your work in Africa and Southeast Asia?

I worked in large hospitals as well as in small community clinics. My work primarily involved teaching local doctors and medical students.

The emphasis is on diagnosis and treatment with limited resources. For example, I tell students "use your stethoscope be cause there is no echo machine available." This type of work is rewarding like nothing else, as students and young doctors in Africa are so smart and well read, it is a pleasure to teach them to connect the pieces and come up with a diagnosis.

Are you conducting any studies in addition to caring for patients?

Research is difficult under African conditions--however, not impossible. I have encouraged local doctors to collect data and publish their work.

Where was your most recent overseas work?

I was in Nairobi to teach a course on AIDS prevention a few months ago, and I just returned from Ethiopia, where I taught a 2-week course on infectious diseases.

What were some of the challenges on your most recent trip to Mekelle, Ethiopia?

Dealing with the unexpected. The course was planned for 30 physicians, 15 nurses, and 5 health workers. On the first day of training, we found to our surprise that we had 23 participants, only 1 of whom was a medical doctor, and no nurses. So we changed the planned schedule, diminished clinical teaching, and focused on lab work.

After the second day, when we only had one physician among the course participants, we were able to communicate with the dean and the district health officer and learned that the interns and students were on vacation that week! This must have been known when the course was planned, but we only found out after 2 days of struggling.

What were the successes of the course?

The third day was the turning point. The students and interns were back and we had 37 participants, including 10 physicians. The teaching was smooth, the rounds on the wards were both revealing and rewarding, and we taught and learned a lot. We succeeded in covering all the subjects on our agenda, including lab diagnosis of infectious disease, host/parasite interaction, bacterial resistance, rational use of antibiotics, AIDS, tuberculosis, lower respiratory infection, and meningitis.

Clinical teaching was performed in the departments of medicine and pediatrics each day, and the students prepared the clinical presentation of the patients. The participants were eager to learn, and we discussed differential diagnosis and management of the cases.

What are some of the challenges for up-and-coming medical practice in Ethiopia, and the opportunities for outside physicians to make a difference?

The teaching hospital in Mekelle has only been open for 5 months. Staffing is problematic, as this is the periphery. The medical school's charter class graduates this year. The size of the class grew from 46 to 80 students, and the government has mandated that the school admit 220 students starting in 2010.

There is no question that the faculty of medicine and the hospital each has a formidable task. Running four schools (medicine, nursing, pharmacology, and public health) simultaneously is difficult, and doing so with a growth rate of more than 200% is almost impossible.

They are short of teachers in all disciplines, and they have recruited foreign teachers from India, Kenya, and Italy. They are also interested in an ongoing program with Ben Gurion University. The next step is to regularly send teachers in internal medicine and pediatrics to spend 2 weeks in Mekelle, accompanied by two students from the School for International Health at BGU In the future these teachers will support the residency program at Mekelle University once it is established.

What do you enjoy most about practicing medicine overseas? What have been some of your greatest challenges?

During the famine in Ethiopia we gave a course on field epidemiology in drought-stricken areas. On day 1 a participant came up to me and asked if I made clinical rounds in the medical college at Jimma (Ethiopia) University 10 years ago. He was my student! And he did not forget my teaching!

What are some features of medical education in Jerusalem that you thought were especially helpful that medical schools in the United States might do well to emulate?

The emphasis on history and physical examination was paramount. Writing up of case histories was critically reviewed by my teachers, and I learned to be a good internist. I think the workload is bigger in Jerusalem than in the United States; there is less time to read and self-learn in Jerusalem, but more time with more patients, and stricter control over what the resident does. The result is better clinical thinking, better bedside manners, and less crude knowledge of the textbook.

What do you believe are the most important elements that should be part of medical education to encourage new physicians to think globally? Do you encourage medical students to spend time practicing medicine in underserved areas?

The school where 1 work [the School for International Health at Ben Gurion University] is a great advocate of this; we send our students for a 7-week structured clerkship in one of eight different locations in the developing world. In addition, teachers from BGU often travel-both to newly established medical schools in the developing world that want to use cutting-edge methods in their education of doctors for the future, and to established schools in developing areas that want to modernize their teaching methods.

Important components in medical education that relate to global health are to make the learner aware of different standards of care and available resources. Cross-cultural work is important in communicating with patients and families, not exclusively in the developing world.

Can you recommend any resources for physicians in the United States who want to get involved with teaching medical students in new medical schools in underserved areas?

Physicians in the United States who want to participate in this program can contact me at malkan@bgu.ac.il and visit the Web site for the School for International Health at Ben Gurion University at web.bgu.ac.il/Eng/fohs/Schools.htm.

Think globally. Practice locally.

U.S.-trained internists who have practiced abroad will receive a $100 stipend for contributing to this column. For details, visit www.worldwidemed.org or send an e-mail to imnews@elsevier.com.

--Interview by Heidi Splete, Senior Writer
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Title Annotation:WORLD WIDE MED
Author:Splete, Heidi
Publication:Internal Medicine News
Article Type:Interview
Geographic Code:1USA
Date:Dec 1, 2008
Words:1455
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